behavioral & psychiatric problems scott marquis, md
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Behavioral & Behavioral & Psychiatric Psychiatric ProblemsProblems
Scott Marquis, MDScott Marquis, MD
What is a behavioral What is a behavioral emergency?emergency?
An unanticipated behavioral An unanticipated behavioral episodeepisode
Behavior that is threatening to Behavior that is threatening to patient or otherspatient or others
Requires immediate intervention Requires immediate intervention by emergency respondersby emergency responders
Abnormal BehaviorAbnormal Behavior
No clear definition, but is No clear definition, but is maladaptivemaladaptive
Deviates from societies norms and Deviates from societies norms and expectationsexpectations
Interferes with individual well-Interferes with individual well-being and ability to functionbeing and ability to function
Harmful to self or othersHarmful to self or others
Behavioral ChangeBehavioral Change
NeverNever assume a patient has a assume a patient has a psychiatric illness until all possible psychiatric illness until all possible physical causes have been ruled physical causes have been ruled outout
‘‘Clues’Clues’Underlying Physical IllnessUnderlying Physical Illness
Sudden onsetSudden onset Visual, but not auditory, Visual, but not auditory,
hallucinationshallucinations Memory loss or impairmentMemory loss or impairment Altered pupil size, asymmetry, or Altered pupil size, asymmetry, or
impaired reactivityimpaired reactivity Excessive salivation or incontinenceExcessive salivation or incontinence Unusual breath odorsUnusual breath odors
Behavioral ChangeBehavioral ChangePossible CausesPossible Causes
Low blood sugarLow blood sugar HypoxiaHypoxia Inadequate cerebral blood flowInadequate cerebral blood flow Head traumaHead trauma Drugs, alcoholDrugs, alcohol Excessive heat or coldExcessive heat or cold CNS infectionsCNS infections
Behavioral Change Behavioral Change PathophysiologyPathophysiology
Biological or organicBiological or organic PsychosocialPsychosocial Socio-culturalSocio-cultural
Organic CausesOrganic Causes
DiseaseDisease Metabolic disorders, infection, Metabolic disorders, infection,
endocrine disorders, neoplastic endocrine disorders, neoplastic disease, cardiovascular disease, or disease, cardiovascular disease, or degenerative diseasedegenerative disease
Physical injuryPhysical injury Head traumaHead trauma
More Organic CausesMore Organic Causes
ToxinsToxins Drug abuse, medication reactions, Drug abuse, medication reactions,
carbon monoxidecarbon monoxide Disturbance in cognitive Disturbance in cognitive
functioningfunctioning Delirium, dementiaDelirium, dementia
EpidemiologyEpidemiology
Mental health problems affect as Mental health problems affect as much as 20% of general populationmuch as 20% of general population
More than all other health problems More than all other health problems combined!combined!
An estimated 1 in 7 persons will An estimated 1 in 7 persons will need treatment for an emotional need treatment for an emotional disturbance at some time in their disturbance at some time in their liveslives
Anxiety DisordersAnxiety Disorders
Most common psychiatric problem Most common psychiatric problem encountered in outpatients encountered in outpatients
Painful uneasiness, a reaction to Painful uneasiness, a reaction to difficult situations or past/present difficult situations or past/present life stressorslife stressors
Interferes with effective functioningInterferes with effective functioning Agitation or restlessness quite often Agitation or restlessness quite often
confused as something elseconfused as something else
Anxiety DisordersAnxiety Disorders
Anxiety, generalizedAnxiety, generalized Panic disordersPanic disorders PhobiasPhobias Obsessive-compulsive disorderObsessive-compulsive disorder Post-traumatic syndromesPost-traumatic syndromes
Mood DisordersMood Disorders
Patient mood ranges from Patient mood ranges from extremely low to euphoric behaviorextremely low to euphoric behavior
May often be more subtle, a loss of May often be more subtle, a loss of interest or enjoyment in any of interest or enjoyment in any of his/her normal pleasureshis/her normal pleasures
Physical complaints are commonPhysical complaints are common
DepressionDepression
Hopelessness, worthlessness, Hopelessness, worthlessness, sleep or eating disturbances, sleep or eating disturbances, unable to concentrate, slowed unable to concentrate, slowed reaction timereaction time
AlwaysAlways ask about suicide! ask about suicide! A factor in 50% of suicidesA factor in 50% of suicides
Bipolar DisorderBipolar Disorder
Manic-depressive cyclesManic-depressive cycles Manic – euphoric, grandiose, Manic – euphoric, grandiose,
pressured, may claim to have pressured, may claim to have special powersspecial powers
Depressed – sad, hopeless, Depressed – sad, hopeless, suicidal, “crash” after maniasuicidal, “crash” after mania
May be delusional in either phaseMay be delusional in either phase
Psychotic DisordersPsychotic Disorders
““A break from reality”A break from reality” Not always a psychiatric cause; Not always a psychiatric cause;
consider alcohol, drugs, and consider alcohol, drugs, and medication reactionsmedication reactions
One percent of general population One percent of general population will be diagnosed with will be diagnosed with schizophreniaschizophrenia
SchizophreniaSchizophrenia
Debilitating distortions of speech Debilitating distortions of speech and thoughtand thought
Bizarre hallucinations, delusions, Bizarre hallucinations, delusions, or behavioror behavior
Social withdrawalSocial withdrawal Lack of emotional expressiveness, Lack of emotional expressiveness,
“flat”“flat”
SchizophreniaSchizophrenia
ParanoidParanoid CatatonicCatatonic DisorganizedDisorganized UndifferentiatedUndifferentiated
Substance-Related Substance-Related DisordersDisorders
IntoxicationIntoxication DependenceDependence WithdrawalWithdrawal
A close friend of psychiatric illnessA close friend of psychiatric illness Particularly tight links to Particularly tight links to
depression and suicidal behavior!depression and suicidal behavior!
SuicideSuicide
NeverNever dismiss any suicidal threat, no dismiss any suicidal threat, no matter how well you know the matter how well you know the patientpatient
Suicide rate in your prehospital Suicide rate in your prehospital population is 10 times that of the population is 10 times that of the general population!general population!
Women attempt suicide more oftenWomen attempt suicide more often Men Men succeedsucceed more often more often
Who is at greatest risk?Who is at greatest risk?
White men over 40White men over 40 Living alone, divorced, or widowedLiving alone, divorced, or widowed Substance abuse problemsSubstance abuse problems Severe depressionSevere depression Past suicide attemptsPast suicide attempts Highly lethal planHighly lethal plan
SuicideSuicide
Asking about a specific suicide Asking about a specific suicide plan will plan will notnot make suicide more make suicide more likely!likely!
Having a detailed plan does put Having a detailed plan does put your patient at higher riskyour patient at higher risk
Suicide Suicide Additional Risk FactorsAdditional Risk Factors
Means are available, low likelihood of Means are available, low likelihood of rescuerescue
Poor physical health; chronic disease Poor physical health; chronic disease or pain syndromeor pain syndrome
Recent loss of a loved one, Recent loss of a loved one, anniversaryanniversary
Sudden life changes; unemployment, Sudden life changes; unemployment, bankruptcy, imprisonmentbankruptcy, imprisonment
Family history of suicide, especially a Family history of suicide, especially a parentparent
Guiding PrinciplesGuiding Principles
Respect the dignity of the patientRespect the dignity of the patient Assure your own as well as the Assure your own as well as the
patient’s and others safetypatient’s and others safety Diagnose and treat organic causes Diagnose and treat organic causes
of behavioral disordersof behavioral disorders Work with law enforcement to Work with law enforcement to
improve patient care outcomesimprove patient care outcomes
Scene Size-UpScene Size-Up
Pay careful attention to dispatch Pay careful attention to dispatch information for indications of information for indications of potential violencepotential violence
Never enter potentially violent Never enter potentially violent situations without police supportsituations without police support
If personal safety is uncertain, If personal safety is uncertain, stand by for policestand by for police
Scene Size-UpScene Size-Up
In suicide cases, be alert for In suicide cases, be alert for hazardshazards Automobile running in closed garageAutomobile running in closed garage Gas stove pilot light blown outGas stove pilot light blown out Electrical devices in waterElectrical devices in water Toxins on or around the patientToxins on or around the patient
Scene Size-UpScene Size-Up
Quickly locate the patientQuickly locate the patient Stay between patient and doorStay between patient and door Scan quickly for any dangerous Scan quickly for any dangerous
articlesarticles If patient has a weapon, ask him/her If patient has a weapon, ask him/her
to put it downto put it down If he/she won’t, back out and wait If he/she won’t, back out and wait
for the policefor the police
Scene Size-UpScene Size-Up
Look for…Look for… Signs of possible underlying medical Signs of possible underlying medical
problemsproblems Methods or means of committing Methods or means of committing
suicidesuicide Multiple patientsMultiple patients
General ApproachGeneral Approach
Do not argue or shout Do not argue or shout Remove disturbing persons or Remove disturbing persons or
objectsobjects Provide emotional supportProvide emotional support Explain all procedures carefully to Explain all procedures carefully to
anxious or confused patientsanxious or confused patients
Initial AssessmentInitial Assessment
Rapid assessment of ABC’sRapid assessment of ABC’s Identify and treat potentially life-Identify and treat potentially life-
threatening illness and injuriesthreatening illness and injuries Observe patient’s outward Observe patient’s outward
behavior and body languagebehavior and body language
Interview ApproachInterview Approach
Communicate in a calm and non-Communicate in a calm and non-threatening, nonjudgmental waythreatening, nonjudgmental way
Identify yourself and offer the Identify yourself and offer the patient assistancepatient assistance
Seek the patient’s cooperationSeek the patient’s cooperation Encourage patient to talk; show Encourage patient to talk; show
you are listeningyou are listening
Interview ApproachInterview Approach
Be supportive and limit Be supportive and limit interruptionsinterruptions
Respect patient’s space, limit Respect patient’s space, limit touching unless given permissiontouching unless given permission
Be direct and always tell the truthBe direct and always tell the truth Involve trusted family, friendsInvolve trusted family, friends
Focused HistoryFocused History
Ask for and acknowledge patient’s Ask for and acknowledge patient’s complaintscomplaints
Determine onset of behavioral eventDetermine onset of behavioral event Ask about precipitating factors; Ask about precipitating factors;
remove patient from these, if remove patient from these, if possiblepossible
Existing life situationExisting life situation Previous psychiatric as well as Previous psychiatric as well as
medical historymedical history
Focused HistoryFocused History
Mental status, affect, and behaviorMental status, affect, and behavior Current medications and alcohol or Current medications and alcohol or
illicit drug useillicit drug use Evaluate potential for suicide!Evaluate potential for suicide!
AssessmentAssessmentSuicidal PatientsSuicidal Patients
Do not trust “rapid recoveries”Do not trust “rapid recoveries” Do something tangible for the Do something tangible for the
patientpatient Do not try to deny that a suicide Do not try to deny that a suicide
attempt occurredattempt occurred NeverNever challenge a patient to go challenge a patient to go
ahead, do itahead, do it
AssessmentAssessmentViolent PatientsViolent Patients
Find out if patient has threatened or Find out if patient has threatened or has history of violence, aggression, has history of violence, aggression, combativenesscombativeness
Assess body language for clues to Assess body language for clues to potential violencepotential violence
Listen for clues to violence in Listen for clues to violence in patient’s speechpatient’s speech
Monitor movements, physical activityMonitor movements, physical activity Be firm, clearBe firm, clear
Physical ExamPhysical Exam
Vital signs and general appearanceVital signs and general appearance Skin examSkin exam Mental statusMental status Evidence for medical problem, Evidence for medical problem,
recent trauma, or an overdoserecent trauma, or an overdose Threat to self or othersThreat to self or others Patient able to provide for needsPatient able to provide for needs
Management PrinciplesManagement Principles
Treat life-threatening medical Treat life-threatening medical problems or traumatic injury first problems or traumatic injury first and foremostand foremost
Hypoxic? Hypoperfused? Hypoxic? Hypoperfused? Temperature extreme? Temperature extreme? Hypoglycemic? Overdose? Hypoglycemic? Overdose? Trauma? Infection?Trauma? Infection?
Management PrinciplesManagement Principles
Maintain scene safety; control any Maintain scene safety; control any violent situationsviolent situations
NeverNever leave the patient alone leave the patient alone Transport patient against his/her Transport patient against his/her
will, if indicatedwill, if indicated Restrain the patient only as last Restrain the patient only as last
resortresort
Restraining PatientsRestraining Patients
A patient may be restrained if you A patient may be restrained if you have good reason to believe have good reason to believe he/she is a danger to:he/she is a danger to: YouYou Himself/herselfHimself/herself OthersOthers
Restraining PatientsRestraining Patients
Have sufficient manpowerHave sufficient manpower Have a plan; know who will do whatHave a plan; know who will do what Use only as much force as needed; Use only as much force as needed;
don’t be punitivedon’t be punitive When the time comes, act quickly; When the time comes, act quickly;
take the patient by surprisetake the patient by surprise Use at least four rescuers, one for Use at least four rescuers, one for
each extremityeach extremity
Restraining PatientsRestraining Patients
Use humane restraints (soft Use humane restraints (soft leather, cloth) on limbsleather, cloth) on limbs
Secure patient to stretcher with Secure patient to stretcher with straps at chest, waist, thighsstraps at chest, waist, thighs
If patient spits, cover his/her face If patient spits, cover his/her face with surgical maskwith surgical mask
Once restraints are applied, never Once restraints are applied, never remove them!remove them!
Chemical RestraintsChemical Restraints
When physical restraints alone are When physical restraints alone are not enoughnot enough
Establish on-line medical controlEstablish on-line medical control Haloperidol (Haldol), 5-10 mg IV or Haloperidol (Haldol), 5-10 mg IV or
IMIM Lorazepam (Ativan), 1-2 mg IV or IMLorazepam (Ativan), 1-2 mg IV or IM Diphenhydramine (Benadryl), 25-50 Diphenhydramine (Benadryl), 25-50
mg IV or IM or hydroxyzine, 50-100 mg IV or IM or hydroxyzine, 50-100 mg IMmg IM
Chemical RestraintsChemical Restraints
Haldol and movement disorders do Haldol and movement disorders do not mix wellnot mix well Worsens extrapyramidal effectsWorsens extrapyramidal effects Minimal anticholinergic and Minimal anticholinergic and
cardiovascular effectscardiovascular effects Ativan ideal for agitation due to Ativan ideal for agitation due to
withdrawalwithdrawal Beware of additive CNS depressant Beware of additive CNS depressant
effecteffect
Chemical RestraintsChemical Restraints
Antihistamines Antihistamines Hydroxyzine useful in drug abusers, Hydroxyzine useful in drug abusers,
little habituationlittle habituation Benadryl can worsen asthma Benadryl can worsen asthma
symptoms and lower seizure symptoms and lower seizure thresholds at higher dosesthresholds at higher doses
Behavioral EmergenciesBehavioral EmergenciesPearlsPearls
Look carefully for physical causes Look carefully for physical causes to explain behavioral emergenciesto explain behavioral emergencies
Pay special attention to your own Pay special attention to your own and others safetyand others safety
Ask about suicide or past violent Ask about suicide or past violent behaviorbehavior
Treat patients fairly and with as Treat patients fairly and with as much dignity as possiblemuch dignity as possible
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