1 What constitutes a psychiatric emergency?

Most practically defined, this is a potentially preventable or treatable condition that threatens:

The patient’s own bodily integrity by suicide, self-mutilation, or drug ingestion

Someone else’s bodily integrity by assault or homicide

The patient’s own psychological and functional integrity (i.e., ability to perceive reality, feel appropriately, make judgments, remember)

The psychological and functional integrity of the family unit.

2 What is the epidemiology of psychiatric illness in children?

Between 6 and 9 million children and adolescents have serious emotional disturbances, and this accounts for 9–13% of all children in the United States.

In addition, only an estimated 20% of children in the United States with some form of mental health problem severe enough to require treatment are actually identified as such, and are receiving mental health services.

Emergency department (ED) visits for psychiatric conditions accounts for 1.6% of all ED visits and 3.2% of visits requiring an inpatient admission.

Sills MR, Bland SD: Summary statistics for pediatric psychiatric visits to US emergency departments, 1993–1999. Pediatrics 110:e40, 2002.

3 Which is the most common psychiatric emergency in children?

Pediatric psychiatric visits to emergency departments in the United States reveal unspecified neurotic disorders (13%), depressive disorders (13%), and anxiety states (11%) as the three most common principal diagnoses; whereas the most common Diagnosis and Statistical Manual of Mental Disorders, 4th edition, axis I disorders are substance abuse (24%), anxiety disorders (17%), and attention deficit and disruptive disorders (11%).

Sills MR, Bland SD: Summary statistics for pediatric psychiatric visits to US emergency departments, 1993–1999. Pediatrics 110:e40, 2002.

KEY POINTS: EPIDEMIOLOGY OF PSYCHIATRIC EMERGENCIES

1 Up to 6–9 million children suffer from serious emotional disturbances, accounting for 9–13% of all children in the United States.

2 Psychiatric conditions account for under 2% of all emergency department visits but for over 3% of emergency department visits requiring inpatient hospitalization.

3 Suicide is the leading cause of death from a psychiatric cause and the third leading cause of death overall in older adolescents.

4 What is the leading cause of death due to psychiatric emergencies?

Suicide is the leading cause of adolescent death due to psychiatric illness and is the third leading cause of death behind accidents and homicides overall in older adolescents.

Sills MR, Bland SD: Summary statistics for pediatric psychiatric visits to US emergency departments, 1993–1999. Pediatrics 110:e40, 2002.

EVALUATION

5 What are the ABCs of the mental status examination in the ED?

A = Appearance/affect: dress/grooming; abnormal movements; eye contact; facial expression; affect (depressed, blunted, flat, anxious, constricted, hostile, euphoric)

B = Behavior: attitude (cooperative, manipulative, guarded, suspicious, angry, violent, withdrawn)

C = Cognition:

Thought content—delusions, suicidal or homicidal; paranoia; somatic preoccupation; depression, obsessions, fears, phobias; belief of special powers; thought control; depersonalization; feelings of helplessness or hopelessness; guilt

Thought process—rate, organization, goal directedness, tangential, flight of ideas

Level of consciousness—orientation, attention, concentration, abstraction

6 How should the initial approach be conducted in evaluating a child with a possible psychiatric emergency?

First, perform an acute medical evaluation, assessing the airway, breathing, circulation, vital signs, and central nervous system (CNS) function, including pupillary response. An assessment for possible toxic ingestions should include a history of all possible medications in the home or accessible to the child, obtained by asking the caregiver and the child, and an identification of possible toxidromes. Obtain a history of potential traumatic injury. Evaluate past medical history that might indicate an organic basis for the acute emergency. Consider laboratory aids, such as electrolytes, glucose, osmolality, blood gas, toxicologic screen, electrocardiography, and cranial computed tomography. Obtain a urine pregnancy test in all adolescent females.

7 List some of the medical considerations of acute psychosis

Trauma: Intracranial hemorrhage

Drug intoxication: Ethanol, barbiturates, cocaine, opiates, amphetamines, hallucinogens, marijuana, phencyclidine, anticholinergic medications (antihistamines, tricyclics), heavy metals, corticosteroids, neuroleptic medications

CNS lesions/infections: Tumor, hemorrhage, temporal lobe epilepsy, abscess/meningitis/encephalitis, HIV

Cerebral hypoxia: Carbon monoxide poisoning, cardiopulmonary failure

Metabolic/endocrinologic: Hypoglycemia, hypocalcemia, hyperthyroidism or hypothyroidism, adrenal insufficiency, uremia, liver failure, diabetes mellitus, porphyria, Wilson’s disease

Collagen vascular diseases: Lupus

Miscellaneous causes: Malaria, typhoid fever, Wilson’s disease, Epstein-Barr virus infection

8 How should the psychiatric evaluation be incorporated into the ED management of a child with a psychiatric emergency?

Once the child has been medically evaluated and organic causes of the mental disturbance have been ruled out, the psychiatric assessment may proceed. The appropriate interview setting is crucial to effectively assess the child’s and family’s crisis. A private room away from the noisy distractions of the main ED setting is optimal. An effort to establish rapport is necessary to engage the child and family to discuss the issues as well as to develop trust. Avoid confrontation and escalation of the crisis, and attempt to de-escalate the arousal of any potentially violent patient. Use psychiatric emergency services and/or social services for the risk assessment of the crisis event.

RESTRAINTS

9 What are the indications for the use of physical restraint or seclusion in the ED setting?

When attempts to provide verbal restraint have been unsuccessful, the following are indications for escalating to physical restraint:

To prevent imminent harm to the patient or other persons when other means of control are not effective or appropriate

To prevent serious disruption of the treatment plan or significant damage to the physical environment

To decrease the stimulation a patient receives (i.e., for those with PCP [phencyclidine] or ethanol intoxications)

When the patient is feeling out of control and requests it

Joint Commission on Accreditation of Healthcare Organizations. 2005 Restraint and Seclusion. Available at www.jointcommission.org/AccreditationPrograms/BehavioralHealthCare/Standards/FAQs/Provision+of+Care+Treatment+and+Services/Restraint+and+Seclusion/Restraint_Seclusion.htm

10 Describe the proper procedure in the use of physical restraint

Explain to the patient why physical restraint is necessary.

Enlist at least five caretakers, one for each limb and one for the head. Avoid pressure on the patient’s throat or chest and keep hands away from the patient’s mouth.

Closely supervise (1:1) the patient in physical restraints; assess restraints at least every 30 minutes and document findings.

Avoid placement of the restrained child in the prone position (this could interfere with ventilation).

Remove restraints only with adequate staff present, and when the patient has regained control (either on his or her own volition, or with the use of chemical restraint).

KEY POINTS: PROPER ADMINISTRATION OF PHYSICAL RESTRAINTS

1 Explain to the patient why physical restraint is necessary.

2 Have at least five caretakers.

3 Avoid pressure on the patient’s throat or chest.

4 Avoid placement of the restrained child in a prone position.

5 Provide close supervision (1:1) while the patient is in physical restraints.

6 Assess restraints at least every 30 minutes and document assessment.

7 Remove restraints only with adequate staff present, and when the patient has regained control.

11 What are the drugs of choice to use as a restraint of a child?

See Table 40-1.

Table 40-1 Drugs of Choice to Use as a Restraint in Children

Drug	Dose	Comment
Benzodiazepines
Diazepam (Valium)	0.1 mg/kg PO or IM/IV	Dose range, 2–10 mg
Lorazepam (Ativan)	0.05 mg/kg PO or IM/IV	Dose range, 1–2 mg with titrated dose every 30 minutes
High-potency neuroleptics*
Haloperidol (Haldol)	0.05 mg/kg PO or IM/IV	Dose range, 2–5 mg
Droperidol (Inapsine)^†	0.05 mg/kg IM/IV	Dose range, 2.5–5 mg
(0.1–0.15 mg/kg maximum dose) (has shorter half-life [2–4 hours] than haloperidol)
Low-potency neuroleptics
Chlorpromazine (Thorazine)	0.5–1 mg/kg PO or IM/IV	Usually 200 mg/d
Thioridazine (Mellaril)	0.5–3 mg/kg PO	May cause hypotension
Antihistamines
Diphenhydramine (Benadryl)	1–2 mg/kg PO or IM/IV	Usually 12.5–75 mg

IM = intramuscularly, IV = intravenously, PO =orally.

Notes: For substance-induced psychosis due to hallucinogens (such as PCP), benzodiazepines given at 30- to 60-minute intervals appear to be more effective than the neuroleptic medications. For substance-induced psychosis due to stimulant intoxication (such as with cocaine or amphetamine), droperidol may be the optimal choice because of its shorter half-life. Some authors advocate concomitant use of antihistamine with neuroleptics to decrease the likelihood of dystonia.

* Children have a slightly higher risk of dystonia compared to adults. Although very rare, neuroleptic malignant syndrome can occur with these medications.

† Droperidol has come under increased scrutiny since the U.S. Food and Drug Administration has issued a “black box” warning because of concerns of a weak association with QT prolongation and torsades de pointes. The extensive experience and safety of this agent in rapid sedation of severely agitated and violent patients leave a quandary with the use of this drug.

Adapted from Shale JH, Shale CM, Mastin WD: A review of the safety and efficacy of droperidol for the rapid sedation of severely agitated and violent patients. J Clin Psychiatry 64:500–505, 2003.

DRUG-INDUCED PSYCHIATRIC EMERGENCIES

12 What is neuroleptic malignant syndrome? How is it treated?

Neuroleptic malignant syndrome (NMS) is an acute, life-threatening reaction to dopamine receptor–blocking agents (typical and atypical antipsychotics) that presents with fever, axial muscular rigidity, autonomic instability/shock, and altered consciousness. An elevated creatine kinase and leukocytosis are common. Treatment is supportive with IV fluids, antipyretics, and stopping the neuroleptic medication. Bromocriptine and dantrolene are specific medications to treat NMS. The differential diagnosis of hyperthermia includes malignant hyperthermia, anticholinergic poisoning, serotonin syndrome, and reactions to sympathomimetics. The presence of rigidity and elevated creatine kinase levels are distinguishing features of NMS that are rare in serotonin syndrome.

13 What is serotonin syndrome? How is it treated?

Given the rise in use of selective serotonin reuptake inhibitors (SSRIs) as well as increased abuse of amphetamines such as ecstasy (MDMA), serotonin syndrome has become more common. The following clinical features must be present: use of SSRI, agitation, stupor, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, diarrhea, incoordination, and fever. Treatment is supportive, with discontinuation of the offending agent.

Rodnitzky RL: Drug-induced movement disorders in children. Semin Pediatr Neurol 10:80–87, 2003.

LEGAL ISSUES

14 What is required for hospital admission of a minor with a psychiatric emergency?

For both involuntary and voluntary, most states require parental consent for commitment of a child under the age of 14 years. In children older than age 12–16 years, many states require consent of the minor. A legal process is required if the child does not consent to voluntary commitment. Most states include some period of emergency involuntary admission, however, this varies greatly from state to state. Commonly, involuntary commitment requires physician (and/or designee) documentation of patient’s danger to self or others and can be in effect for several days without a court order (depending on state statutes). In general, there are more inpatient psychiatric units that will accept patients under voluntary commitment than under involuntary commitment.

Fortunati FG, Zonana HV: Legal considerations in the child psychiatric emergency department. Child Adolesc Psychiatr Clin North Am 12:745–761, 2003.

DEPRESSION AND SUICIDAL IDEATION

16 How can a clinician assess the presence of depression and suicidal potential of the depressed patient?

A modified SAD PERSONS Scale has been developed and used in the adult and adolescent populations (Table 40-2).

Table 40-2 Modified Sad Persons Scale

Mnemonic	Characteristic	Score
Sex	Male	1
Age	<19 or >45 years	1
Depression/hopelessness	Admits to depression; poor concentration, appetite, or sleep	2
Prior attempts/psychiatric care	Prior inpatient or outpatient care	1
ETOH/drug use	Addiction or frequent use	1
Rational thinking lost	Psychosis	2
Single/separated/divorced		1
Organized/serious attempt	Life-threatening presentation, careful plan	2
No social supports	No family, friends, religious associations	1
Stated future intent	Determined to repeat, ambivalent	2

ETOH = ethanol.

A score > 6 suggests 1:1 observation and acute psychiatric evaluation; a score > 10 suggests psychiatric inpatient hospitalization.

Adapted from Hockberger RS, Rostein RJ: Assessment of suicide potential by nonpsychiatrists using the SAD PERSONS Score. J Emerg Med 6:99–107, 1988.

17 What questions have been identifed as useful in screening for suicide risk?

The abbreviated (four-item) Suicide Ideation Questionnaire (SIQ) has high sensitivity (98%) and negative predictive value (97%) and can be used as a screening tool to detect suicidality in children and adolescents.

1 Are you here because you tried to hurt yourself?

2 In the past week, have you been having thoughts about killing yourself?

3 Have you ever tried to hurt yourself in the past other than this time?

4 Has something very stressful happened to you in the past few weeks?

Horowitz, LM, Wang PS, Koocher GP, et al: Detecting suicide risk in a pediatric emergency department: Development of a brief screening tool. Pediatrics 107:1133–1137, 2001.

18 What are some medical conditions associated with depression?

Neurologic: Hydrocephalus, migraine, myasthenia gravis, seizure, tumor

Endocrine: Adrenal insufficiency, type 1 diabetes, hyperthyroidism or hypothyroidism, menses-related condition, postpartum status

Metabolic: Hypercalcemia or hypocalcemia, hyponatremia, uremia, porphyria, Wilson’s disease

Infectious/inflammatory: HIV, influenza, Epstein-Barr virus, hepatitis, collagen vascular diseases

Co-occurring illness: Cancer, hypothyroidism, systemic lupus erythematosus, HIV, diabetes, epilepsy

Guerrero APS: General medical conditions in child and adolescent patients who present with psychiatric symptoms. Child Adolesc Psychiatr Clin North Am 12:613–628, 2003.

19 What are some medications associated with depression?

See Table 40-3.

Table 40-3 Medications Associated with Depression

Category	Specific Medications
Neuropsychiatric	Neuroleptics, barbiturates, benzodiazepines, carbamazepine, phenytoin, stimulants
Antimicrobial	Ampicillin, griseofulvin, metronidazole, trimethoprim
Anti-inflammatory/analgesic	Corticosteroids, opiates
Cardiovascular	Clonidine, propranolol
Miscellaneous	Chemotherapy, ethanol, caffeine, oral contraceptives