Psychiatric Emergencies

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Chapter 40 Psychiatric Emergencies

Philip V. Scribano, DO, MSCE

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).

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