1 What constitutes a psychiatric emergency?

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

2 What is the epidemiology of psychiatric illness in children?

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.

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.

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

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

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.

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:

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

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

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.

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.

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.

15 Identify risk factors for suicidal attempts in children and adolescents

Recent psychosocial stressor, family history of mental illness, relationship with parents or guardians, history of physical or sexual abuse, and sexual orientation are additional factors to elicit to assess suicidal risk.

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

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.

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?

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

Adapted from Milner KK, Florence T, Glick RL: Mood and anxiety syndromes in emergency psychiatry. Psychiatr Clin North Am 22:755–777, 1999.

20 Describe the specific ED management issues in the evaluation of a child with depression or suicidal ideation

First, assess the potential medical causes of the child’s depression, with specific attention to evaluation of toxic ingestions. Maintain suicide precautions with 1:1 observation until the patient has been fully evaluated regarding this risk. Search the patient and his or her personal belongings for possible harmful objects.

21 List essential criteria for outpatient disposition of the suicidal child/adolescent

Kennedy SP, Baraff LJ, Suddath RL, Asarnow JR: Emergency department management of suicidal adolescents. Ann Emerg Med 43:452–460, 2004.

22 How often do children with aggression and violence present to the ED?

Aggression or dangerous behavior is often the final common pathway from a variety of causes, such as psychosis, child maltreatment, mood disorders, and behavioral/cognitive deficiencies. Twenty-five percent of adolescent emergency psychiatric presentations are due to this phenomenon.

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

23 In assessing the child with aggression, what key information is necessary to accurately evaluate the cause of this behavior?

Providers must obtain a history of: the onset of the symptoms and their severity; use of weapons; injury to self or others, including animals; indications of intent to harm and lethality; presence of other related symptoms; response to limit setting; destruction of property, including history of firesetting; and the presence of precipitants versus impulsive acts.

24 What approach is suggested to address the child with aggression?

Clinicians must avoid responding to the patient’s aggression in a punitive manner. A respectful, nonjudgmental, and reassuring attitude fosters an internal rather than external effort in gaining control for the patient and can reduce the aggressive behavior.

25 Is it possible to provide oral medications to an agitated/ aggressive child?

Most patients will cooperate with an oral dosing of a medication, despite the belief that they may be too agitated and uncooperative. Aggressive behavior frequently causes shame and embarrassment to the child. As such, actions that reflect a respectful, nonjudgmental and reassuring attitude, such as offering the patient the option of oral medication versus “a shot,” can accomplish much in reducing the agitation and additionally avoid any potentially punitive medical provider response. Lastly, for some sedatives, oral administration can be as effective as intramuscular dosing to control agitation, and the onset of intramuscular dosing is not significantly more rapid to warrant its routine, first-line use.

Yildiz A, Sachs GS, Turgay A: Pharmacological management of agitation in emergency settings. Emerg Med J 20:339–346, 2003.

26 What are the four diagnostic criteria for anorexia nervosa?

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.

27 What are some of the medical complications of persistent purging or starvation seen in anorexia nervosa or bulimia?

Miller KK, Grinspoon SK, Ciampa J, et al: Medical findings in outpatients with anorexia nervosa. Arch Intern Med 165:561–566, 2005.

28 What is the initial medical evaluation for a patient with a suspected eating disorder?