Psychiatric Emergencies in Clinical Practice Part 2: Common Problems

Transcription

1 Psychiatric Emergencies in Clinical Practice Part 2: Common Problems Office of Medical Services CME Buenos Aires February 2012 Stephen A. Young, MD RMO/P Bogota Region 1 Suicidal Ideation 2 1

2 Suicide: The Obligatory Statistics Slide 11 th leading cause of death in the US 3 rd cause of death ages Firearms used 55% of time (Anderson and Smith 2003) In 2002, 132,353 hospitalized following suicide attempts and 116, 639 were treated in ERs and released (about 1/4 million total) (CDC, 2004) 3 But..the only patient that really matters is the one sitting in front of you.. 4 2

3 Some statistics that can help identify patients at risk The two groups at highest risk are those below 20 and those above 50 Women attempt 3-4 X as frequently as men, but men use more lethal means and are 2-3 X more often successful Suicide is much more common in patients with an established psychiatric disorder and this increases when combined with substance abuse 5 SAD PERSONS : Quick Review of Suicide Risk Factors S: Sex A: Age D: Depression P: Previous Attempts E: Ethanol Abuse R: Rational Thinking Loss S: Social Supports Lacking O: Organized Plan N: No Spouse:Divorced>Widowed>Single S: Sickness (esp chronic conditions/pain) 6 3

4 Ways to Quantify Specific Risks Lethality: How specific is the plan? Could it succeed? Could the person be found? Hopelessness: This has emerged as a critical element in highly suicidal patients are there protective factors present? (family, religion, higher level defense mechanisms) What has kept them alive so far? Suicide is very personal patients must be approached in an empathic and nonjudgmental fashion 7 Prior to Med Evac Safety is the number one concern RSO may need to be involved to remove weapons from residence or to assist with secure environment Front Office needs to know what s going on MED/MHS in WDC needs to be informed In absence of local inpatient treatment facility patients may need to be monitored in their residence or other secure setting and will almost always require a medical attendant 8 4

5 Panic Attacks 9 Panic Attacks At Least 4 Symptoms, Peak in 10 Minutes Heart and Lung CNS GI Psyche 1. Palpitations, pounding heart, or accelerated heart rate 2. Chest Pain or discomfort 3. Shortness of breath 4. Feeling of choking 5. Feeling of dizzy, unsteady, lightheaded or faint 6. Paresthesias (numbness or tingling sensations) 7. Chills or hot flushes 8. Trembling or shaking 9. Sweating 10. Nausea or abdominal stress 11. Derealization (feelings of unreality) or depersonalization (being detached) 12. Fear of losing control or going crazy 13. Fear of dying 10 5

6 Panic Disorder (cont) Typical Attack lasts just a few minutes the recovery time can be several minutes to hours in length Morbidity results from learned reaction to event avoidance of situations associated with attacks Over time, the avoidance becomes more and more disabling as the individual s comfort zone shrinks This cognitive element ultimately becomes the most difficult aspect of the illness to treat

7 Differential Diagnosis Hyperthyroidism Hypoglycemia Excessive Caffeine Use Cardiac Event Pulmonary Embolus Pheochromocytoma Carcinoid 13 Treatment Principles: Pharmacotherapy Benzodiazepines effective and not always a bad idea Longer half life agents have a number of advantages over shorter half life agents Antidepressants found effective in multiple studies spanning decades (both Tricyclics and SSRIs) but NOT Wellbutrin Best approach may be a strategy that combines benzodiazepine for short term symptom relief with antidepressant for longer term management 14 7

8 Sample Treatment Regimen Week 1: Clonazepam 0.5 mg bid plus Zoloft 25 mg qd Week 2 and 3: Clonazepam 0.5 mg bid plus Zoloft 50 mg qd Week 4: Clonazepam 0.5 mg q AM plus Zoloft 50 mg qd Week 5: Zoloft 50 mg qd 15 Alcohol Related Emergencies 16 8

9 Alcohol Related Emergencies Acute Intoxication Acute Alcohol Poisoning Aggression with other employees and family members Alcohol Withdrawal Medical conditions directly related to alcohol use (GI bleeds, pancreatitis, ascites, Wernicke Korsakoff delirium/dementia)

10 Management of Intoxication and Withdrawal: Alcohol Poisoning Intoxicated patients need to be monitored do not put them in a room to sleep it off Alcohol in the stomach can raise ETOH levels even if the patient doesn t seem that bad CNS depressant effect suppresses gag reflex and respiration leading to aspiration, stupor and death Key signs: confusion, excess vomiting, seizures, and slowed respiratory rate Key intervention is early recognition and supportive care often in ICU 19 Signs/Symptoms of Withdrawal Autonomic Instability (elevated BP and HR) Nausea Anxiety Diaphoresis Tremors Agitation Disorientation Visual, Tactile, and/or Auditory Hallucinations 20 10

11 21 When to Treat? First 48 hours are key because that is when seizure risk is greatest Don t wait for full blown symptoms Previous history of significant withdrawal indicates early proactive treatment Diastolic BP or HR > 100 CIWA-Ar score >

12 How to Treat? Benzodiazepines still the core treatment Clonidine will prevent autonomic symptoms but no seizure prophylaxis Short vs. Half life benzos Advantage to long half life (Librium, Valium) is self tapering Advantage to short half life (Lorazepam) is no active metabolites, can control risk of respiratory depression better 23 Typical Regimens Chlordiazepoxide (Librium) mg q 4-6 hours x 2-3 days targeted to withdrawal symptoms Lorazepam 1.0 mg q 4-6 hours Diazepam 5-10 mg q 4-6 hours or 20 mg q two hours until patient sleeping Thiamine 100 mg po qd 24 12

13 25 More Severe Syndromes: Delirium Tremens Patients with a history of previous withdrawals or DTs at the highest risk Confusion, Hallucinations (visual and tactile), and severe autonomic instability Patients often have medical co-morbidity due to alcoholic lifestyle (malnutrition, infectious disease, exposure) Can be life threatening and requires emergency treatment/icu for stabilization 26 13

14 Post Partum Depression and Psychosis 27 DOS Births 2010: 320 DOS Births 2011: 340 (first 11 months) 28 14

15 Post Partum Depression/Psychosis Large number of reproductive age women in DOS Additional psychosocial stressors of life overseas, med evac, language barriers with local Obs etc 50-85% of women experience baby blues normal 10-20% post partum depression % post partum psychosis Post partum psychosis is a psychiatric emergency! 29 Postpartum Depression: Prevention Recognize patients who may be at risk: Previous history of mood disorders Family history of mood disorders First pregnancy Psychosocial Stressors Treat: Supportive therapy Address psychosocial issues Close monitoring/medication after delivery 30 15

16 Postpartum Psychosis: Management Post partum patients who present with poor self care, paranoid delusions, and/or fantasies of harming themselves or baby need to be taken very seriously If these symptoms manifest make sure Mom is monitored at all times utilize family members, friends, and HU personnel Medevac indicated as soon as possible 31 The Acutely Psychotic/Agitated Patient 32 16

17 Acute Agitation The first rule is always safety first; never chase a patient down a hallway or engage in a physical confrontation Sometimes effective medical assessment may take a back seat to getting the patient under physical control Often you may be called to a scene where an individual is already in some type of custody/control Aggression/Loss of Control does NOT automatically mean the individual is mentally ill! 33 Aggression in Embassy/HU Situations Fortunately not common Most likely scenarios: Interpersonal conflicts Intoxication or Withdrawal Family conflict (adolescents v. parents or spouse v. spouse) Autism/MR patients who become frightened or disoriented Acute psychosis Dementia and other cognitive disorders 34 17

18 35 Again..Safety First: Management Approach the patient in a calm, non confrontational manner Identify yourself and make it clear your intention is to assist Be firm, direct, and concrete Listen If possible, obtain VS and do an overall assessment of the patients current status (restless, disheveled, injured etc) If the patient cannot be verbally de-escalated move to restraint/medication 36 18

19 Management: Pharmacotherapy All HU formularies should have a few doses of injectable benzodiazepines and antipsychotics Antipsychotic often not required especially if psychosis is not likely Lorazepam 2 mg IM is an excellent choice IF the patient appears psychotic Can combine Haldol 5 mg with Lorazepam 2 mg and Benedryl 25 mg ALWAYS give the patient the choice to take meds po if possible 37 Suggestions for Using Restraints At least 5 people: one for each extremity and one to control the head Keep talking to the patient; explain what is happening Give the client a few seconds to comply but don t negotiate Patient should be monitored at all times, especially monitor extremity perfusion, level of consciousness, and respiratory status Goal is to restrain for the shortest time possible 38 19

20 Family Advocacy 39 Family Advocacy Cases Child Abuse Child Neglect Domestic Violence 3 FAM 1810 FAC-Wash DC: Drs. Paul Beighley & Stanley Piotroski: Consult with RMOP; RMO; FSHP 40 20

21 Family Advocacy Cases Always complex, always emotional. Front office at post may have limited to no experience and look to you for guidance. Control Information Flow Need to Know only DCM, RSO, and FAC in WDC Medical Officer Evaluates RSO Investigates Both Medical Officer and RSO report separately to WDC 41 Family Advocacy Cases (cont) WDC reviews the situation and provides guidance Do not delay in providing information if there is a credible allegation the FAT should meet ASAP and WDC contacted immediately RSO will make determination re: safety at post (e.g., do the parties need to be separated right away?) Med evac may be complex as parties may not travel together 42 21

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