Lance H. Hoffman
EPIDEMIOLOGY
Mental health-related visits to US emergency departments increased 38% to 23.6 per 1000 population in the last two decades.
Patients who are suicidal, homicidal, or violent or have a rapidly progressive medical condition resulting in abnormal behavior require stabilization.
CLINICAL FEATURES
Suicidal patients are often forthcoming about their intentions for self-harm; however, the patient’s intentions may be more difficult to infer if a nontraumatic suicide attempt has been made or the patient has an altered level of consciousness.
Risk stratification schemes for suicidal patients should be used (Table 187-1).
TABLE 187-1 Evaluation of Suicide Risk in Adults and Adolescents
Patients with schizophrenia, substance abuse, and depression are at higher risk of being suicidal.
A high index of suspicion for depression should be maintained in patients with vague, seemingly unrelated, somatic complaints.
Medication overdose is the most common type of suicide attempt.
The language of potentially violent patients may contain profanity, escalate in volume, and be rapid or pressured.
Mannerisms suggestive of a potentially violent patient include restlessness, pacing in the examination room, clenched fists, acts of violence directed toward inanimate objects in the room, and hypervigilance.
DIAGNOSIS AND DIFFERENTIAL
Differentiating medical (organic) and psychiatric etiologies is important to appropriately managing the patient demonstrating abnormal behavior.
Evaluation includes a detailed history of present illness, past medical and psychiatric history, medication history, social history, and a physical examination.
Important components of the mental status examination are documentation of the patient’s physical appearance, affect, orientation, speech pattern, behavior, level of consciousness, attention, language, memory, judgment, thought content, and perceptual abnormalities.
Multiple clinical features can be associated with organic etiologies of abnormal behavior (Table 187-2).
A variety of reversible medical conditions might result in the acute onset of a behavioral abnormality including hypoglycemia, hypoxemia, hypertensive encephalopathy, meningitis or encephalitis, head trauma, seizure, intracranial neoplasm, stroke, acute organ system failure, delirium secondary to infection, endocrinopathy (thyroid parathyroid, or adrenal), and substance intoxication, poisoning, or withdrawal.
A third-party account of the patient’s behavior as it compares with the patient’s normal behavior and level of functioning is important to obtain.
Important historical information includes the presence of previous psychiatric illness, fever, head trauma, infections, ingestion of medications or legal and illegal substances, disorientation or confusion, impaired speech, syncope or loss of consciousness, headaches, and difficulty performing routine tasks.
All abnormal vital signs should be investigated and corrected before attributing the patient’s abnormal behavior to a psychiatric etiology with special attention being devoted to discovering signs of trauma, infection, substance abuse, endocrine disorders, and disorders of the central nervous system.
Visual hallucinations tend to be more suggestive of a medical etiology, whereas auditory hallucinations tend to support a psychiatric etiology.
If the patient is unable to draw a clock face correctly with the hands reading a specific time designated by the examiner, then a medical etiology of the behavio ral abnormality is likely.
Determining the patient’s capillary glucose concentration and oxygen saturation on room air is critical in rapidly excluding hypo- or hyperglycemia and hypoxemia as potential causes of the patient’s altered behavior.
Obtaining a urinalysis to evaluate for urinary tract infections resulting in delirium is important in the elderly individual.
Additional tests that can be useful depending on the clinical situation include a complete blood count, serum electrolytes, creatinine, hepatic enzymes, T4 level, TSH, ethanol, urine drug screen, pregnancy test, arterial blood gas analysis, cerebrospinal fluid analysis, electrocardiogram, and computed tomography or magnetic resonance imaging of the brain.
Salicylate and acetaminophen levels also are useful in the suicidal patient.
TABLE 187-2 Features Associated with an Organic Cause of Psychosis
Abnormal vital sign values
Disorientation with clouded consciousness
Abnormal mental status examination findings
Recent memory loss
Age >40 y without a previous history of psychiatric disorder
Focal neurologic signs
Visual hallucinations
Psychomotor retardation
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Emergency psychiatric evaluation should be prioritized in a stepwise fashion (Table 187-3).
Violent patients should be physically and chemically sedated to avoid self-injury and harm to nearby individuals.
An algorithmic approach can be used to safely chemically sedate an agitated patient (Fig. 187-1).
FIG. 187-1. Suggested algorithm for the ED management of patients with acute undifferentiated agitation. *Droperidol dosing may be repeated if clinically indicated. †Consider reduced dosing in the elderly; lorazepam, 1 milligram IM, haloperidol, 2 milligrams IM, and ketamine, 2 milligrams/kg IM.
Suicidal and homicidal or violent patients should be disrobed, gowned, and searched for potentially dangerous items.
The clinician should approach the violent patient with a nonthreatening voice and posture while avoiding excessive eye contact and keeping the room’s exit easily accessible.
Enforceable limits as to what constitutes acceptable behavior by the patient must be set by the clinician.
After excluding a medical (organic) etiology for the patient’s abnormal behavior, patients judged to be at high risk to themselves or others or who are unable to effectively care for themselves while alone should be admitted to a psychiatric facility for definitive care.
Patients whose evaluation demonstrates a medical etiology for their behavioral change should receive appropriate medical therapy specific to the disorder, and hospital admission is necessary if the disorder is not readily reversible, is likely to recur or progress, or if the patient’s behavior remains such that independent living would be dangerous.
TABLE 187-3 Emergency Psychiatric Assessment Steps
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 283, “Behavioral Disorders: Emergency Assessment,” by Gregory Larkin and Annette Beautrais, and Chapter 285, “Psychotropic Medications and Rapid Tranquilization,” by Marc Martel and Michelle Biros.