Click here to view next page of this article New Advances in Emergency PsychiatryWhen the psychiatrist is called to the emergency room because the patient is confused; somebody who is not acting their normal self the treatment should quickly rule out the potentially lethal and continue or refer their workup as appropriate for their subacute or sublethal condition. The patient can’t tell you what’s going on. They are having confusion, so you need somebody else to tell you, to give you part of the history. Elderly people are more apt to become confused. Treatment of confusion. Number one treat the underlying cause, then treat agitation if present. Severe anxiety. Because we want to distinguish between panic attacks and generalized anxiety disorder, which we will talk about later in the day. Is it new? Again, it kind of goes along with the confusion. If this is new then it’s more of an emergency type of thing. If it’s not new, then we are not as worried about it from an emergency perspective. Although you still may have to deal with it as a physician. Has it been worked up and/or treated? What’s your medical history? Any psychiatric or substance abuse? Important question: how much caffeine do you use? Treatment of severe anxiety. In the emergency department, 1-2 mg of Ativan is a very good standard. Some people like to use Xanax. But I think Ativan is a really good standard. When you are choosing a benzodiazepine I like … another reason Ativan is a good choice as a sort of The suicidal patient. About 30,000 suicides annually in the U.S. Suicide is very impulsive. That’s why people with substance abuse are at particular risk for suicide because they get drunk - I’ve seen it over and over. You work in an ER or you do consulting as a psychiatrist in an ER. Risk factors for suicide: the older you get, the more you are at risk for suicide. Elderly males have the highest rate of suicide. Management of the suicidal patient: somebody comes into the ER or your office and they are talking about suicide, what do you do? Number one, try to assess the seriousness of the risk. Does it seem real? And there’s no science to this. A lot of people who kill themselves really are a mystery. They will have a freezer and a refrigerator full of food, they will have recently renewed all their magazine subscriptions. It’s really a mystery and I think one of the answers to that mystery is what I said before. Violent patients. There’s two kinds of really violent patients. There’s one where they are agitated secondary to confusion, and the other where they are just kind of sociopathic and criminal. Number one: assess and treat the medical issues above. Use Haldol and lorazepam. Tips for dealing with aggression. Avoid any verbal confrontation if possible. Offer food and cold liquids. I once saw a psychiatric outline in a course like this where they said, offer the patient coffee. Agitated patients, coffee, no. Not unless you want to be wearing it. Let the patient vent. This is so important. Chlorpromazine or Thorazine can cause hypotension. Get these elderly people, or even young people, and they suddenly go from agitated to on the floor, clunk. Then you have to call the radiologist. Apart from drugs, non-pharmacological options is letting the patient vent. Supportive therapy, including cooling blankets, ice baths, hydration, maybe Tylenol. How about dantrolene and bromocriptine? In real life, probably not. For the Board, probably so. I don’t think in looking at the literature, and I’m not the internationally recognized authority on NMS, but looking at the literature I don’t think that bromocriptine or dantrolene. Hypokalemia: one of those is because of poor nutrition and another is eating disorders. These bulimic women - and believe me, it tends to be a disease of women - will vomit, will make themselves vomit and then they will get hypokalemic. Also, here’s a trivia question. EKG abnormalities: thioridazine can cause quinidine-like effects, such as prolonged TP and CR intervals. That’s important to know. Mellaril, or thioridazine, that is the least heart-healthy of your antipsychotics probably. Lithium can cause T-wave flattening or inversion. Looks like hypokalemia. TCA overdose, classically QRS widening and anorexia can result in bradycardia or other arrhythmias. There is one where you’ve got to get an EKG. Lithium, no question. You want an EKG. There were a few tragic deaths with one of the TCAs, desipramine I believe. There were a few kids who died unfortunately, in a relatively short period of time, because they were put on desipramine. There were like six kids and in a short period of time three of them died. Serum iron and mental status changes: when people are anemic they can feel kind of low, sluggish. That’s one of the symptoms of iron-deficiency anemia. |