General psychiatric approach: Difference between revisions
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*Pending results should not delay transfer or evaluation | *Pending results should not delay transfer or evaluation | ||
*Patient’s cognitive abilities, rather than specific blood alcohol level, should dictate initiation of psychiatry evaluation | *Patient’s cognitive abilities, rather than specific blood alcohol level, should dictate initiation of psychiatry evaluation | ||
===Risk Assessment=== | |||
Use clinical judgment along with structured tools (e.g., SAD PERSONS, Columbia Suicide Severity Rating Scale) to assess: | |||
* Suicide risk (plan, means, intent) | |||
* Homicidal ideation or violent behavior | |||
* Gravely disabled or unable to care for self | |||
* Risk to others (e.g., psychosis, [[Hallucinations|command hallucinations]]) | |||
* Access to firearms or lethal means | |||
==Management== | ==Management== | ||
Revision as of 16:49, 5 May 2025
Background
- Be wary of diagnostic overshadowing (e.g. erroneously attributing symptoms of medical illness to psychiatric disease)
Clinical Features
Mental Status Exam
- General Appearance
- Orientation and Attention
- Speech
- Mood and affect
- Thought Patterns (process, content)
- Psychomotor behavior
- Insight and Judgement
Differential Diagnosis
General Psychiatric
- Organic causes
- Psychiatric causes
Evaluation
- Rule out medical pathology as cause or exacerbating factor for presentation
General ED Psychiatric Workup
- Point-of-care glucose
- CBC
- Chem 7
- LFTs
- ECG (for toxicology evaluation)
- ASA level
- Tylenol level
- Urine toxicology screen/Blood toxicology screen
- EtOH
- Urine pregnancy/beta-hCG (if female of childbearing age)
- Consider:
- Ammonia (see Hepatic encephalopathy)
- TSH (hypo or hyperthyroidism may mimic mental illness)
- CXR (for Tb screen or rule-out delirium in older patient)
- UA (for rule-out delirium in older patients)
- Head CT (to rule-out ICH in patients with AMS)
- Lumbar puncture (to rule-out meningitis or encephalitis)
- Sad person's score
ACEP Guidelines 2005
- Class B recommendations
- Routine laboratory testing is of low yield and unnecessary
- Routine urine toxicology need not be performed
- Pending results should not delay transfer or evaluation
- Patient’s cognitive abilities, rather than specific blood alcohol level, should dictate initiation of psychiatry evaluation
Risk Assessment
Use clinical judgment along with structured tools (e.g., SAD PERSONS, Columbia Suicide Severity Rating Scale) to assess:
- Suicide risk (plan, means, intent)
- Homicidal ideation or violent behavior
- Gravely disabled or unable to care for self
- Risk to others (e.g., psychosis, command hallucinations)
- Access to firearms or lethal means
Management
General ED Psychiatric Management
- Non-pharmacologic
- Verbal de-escalation
- Offer comforting items: blanket, meal, pillow, etc
- Quiet room
- Physical restraints (should administer medications if restraints used, as decreases restraint time)
- Pharmacologic: Goal is to calm patient without oversedation
- No history of psychosis
- Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
- Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
- Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg (PO/IM/SL) or ziprasidone 10-20mg IM
- Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
- Known or suspected underlying psychotic illness
- Continue treatment with previous antipsychotic or
- PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
- IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
- (PO/IM/IV) Haloperidol 0.5-5mg +/- lorazepam 0.5-2mg
- Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
- No history of psychosis
Disposition
See Also
External Links
References
- ↑ Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333
- ↑ Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333.
- ↑ Mai Q, D’Arcy C, Holman J, Sanfilippo FM, Emery JD, et al. (2011) Mental illness related disparities in diabetes prevalence, quality of care and outcomes: a population-based longitudinal study. BMC Med 9: 118.
- ↑ https://www.cdc.gov/mentalhealth/data_stats/mental-illness.htm
- ↑ Disability Rights Commission (2006) Equal Treatment: Closing the Gap. A Formal Investigation into Physical Health Inequalities Experienced by People with Learning Disabilities and/or Mental Health Problems. Disability Rights Commission. London.