Psychosis, Substance Psychosis, Substance AbuseAbuse

Suicide/HomicideSuicide/Homicide

Self-Directed Learning Self-Directed Learning AssessmentAssessment

Nikki Waller, MDNikki Waller, MD

2009-20102009-2010

ObjectivesObjectives

• Discuss recognition, initial Discuss recognition, initial stabilization, and department stabilization, and department management of management of – Acute psychosisAcute psychosis– Substance abuseSubstance abuse– Suicide/homicideSuicide/homicide

PsychosisPsychosis

• Abnormal thought patterns, with Abnormal thought patterns, with intact cognitionintact cognition

• Usually due to mental disorders, but Usually due to mental disorders, but can be from acute drug intoxication can be from acute drug intoxication or chronic abuseor chronic abuse

• Most important are schizophrenia, Most important are schizophrenia, mania, and depression in the setting mania, and depression in the setting of the EDof the ED

SchizophreniaSchizophrenia

• Delusions and hallucinationsDelusions and hallucinations• Most common of the psychosesMost common of the psychoses• Mood is usually unaffected and flatMood is usually unaffected and flat• May present quiet and withdrawn or May present quiet and withdrawn or

violent, paranoid and suspiciousviolent, paranoid and suspicious• Neuroleptics are the mainstay of Neuroleptics are the mainstay of

treatment chronically and acutelytreatment chronically and acutely• Often present because they have Often present because they have

stopped taking medsstopped taking meds

ManiaMania

• Often associated with bipolar disorderOften associated with bipolar disorder

• Elevated mood and energyElevated mood and energy

• Acute mania: fast and pressured speech, Acute mania: fast and pressured speech, agitation, grandiose delusions, and agitation, grandiose delusions, and insomniainsomnia

• Can be violentCan be violent

• sedating neuroleptics are often neededsedating neuroleptics are often needed

• Lithium for chronic use, but not in the acute Lithium for chronic use, but not in the acute settingsetting

DepressionDepression

• Rare to present with psychotic Rare to present with psychotic featuresfeatures

• Usually not violent or agitatedUsually not violent or agitated

EvaluationEvaluation

• Should be a plan in the Should be a plan in the ED to deal with violent or ED to deal with violent or abusive patientsabusive patients

• Obtain as much info as Obtain as much info as possible from patient, possible from patient, family, paramedics etc.family, paramedics etc.

• Try to obtain history prior Try to obtain history prior to restraints or sedativesto restraints or sedatives

• May not be able to obtain May not be able to obtain any reliable historyany reliable history

• May need to interview May need to interview with security present if with security present if patient is violent/agitatedpatient is violent/agitated

• Workup should be Workup should be guided by h and p. guided by h and p.

• If known psychiatric If known psychiatric disorders may require disorders may require basic labs, drug levels, basic labs, drug levels, tox/etoh screens, lytestox/etoh screens, lytes

• If new or worsened If new or worsened presentation, would presentation, would need exclusion of need exclusion of organic causes (uti, organic causes (uti, drug ingestion, head drug ingestion, head injury etc)injury etc)

TherapyTherapy

• Ensure patient and Ensure patient and healthcare worker healthcare worker safety first.safety first.

• Glucose, o2, Glucose, o2, thiamine, narcan, thiamine, narcan, and possibly and possibly flumazenil first for flumazenil first for acutely delusional acutely delusional patient may patient may improve statusimprove status

• Restraint options:Restraint options:– Seclusion (must be Seclusion (must be

watched)watched)– Physical restraints (if Physical restraints (if

necessary, but also necessary, but also must be watched)must be watched)

– Drugs: droperidol, Drugs: droperidol, haldol, ativan, haldol, ativan, geodongeodon

– Start with small doses Start with small doses and watch for and watch for sedative effects.sedative effects.

DispositionDisposition

• Consult psych, frequent documentation Consult psych, frequent documentation of status if restrained.of status if restrained.

• Involuntary commitment if necessaryInvoluntary commitment if necessary

• Must rule out drug/etoh intoxication or Must rule out drug/etoh intoxication or other reversible cause before they are other reversible cause before they are “cleared from a medical standpoint” to “cleared from a medical standpoint” to be considered only psych. be considered only psych.

Depression and SuicideDepression and Suicide

• Depression Depression – most common most common

psychiatric disorder psychiatric disorder (2-3%)(2-3%)

– Persistent dysphoric Persistent dysphoric mood or loss of mood or loss of interest in activities interest in activities for at least 2 weeksfor at least 2 weeks

• SuicideSuicide– 22ndnd leading cause of leading cause of

death among death among teens/young adultsteens/young adults

– Women attempt Women attempt more often, more often,

– Men more likely Men more likely successfulsuccessful

Clinical FeaturesClinical Features• Guilt and hopelessnessGuilt and hopelessness

• Thoughts of death or Thoughts of death or suicidesuicide

• Change in Change in appetite/weightappetite/weight

• Insomnia/excessive Insomnia/excessive sleepsleep

• FatigueFatigue

• Difficulty concentratingDifficulty concentrating

• Can be situationalCan be situational

• Can be medical causes Can be medical causes (hypothyroidism)(hypothyroidism)

• Need Pmhx, Need Pmhx, psychiatric problems, psychiatric problems, meds hx meds hx

• Risk assessment is Risk assessment is KEY:KEY:

• Ask about homicide, Ask about homicide, suicide, specific plan, suicide, specific plan, and what their access and what their access is to those plans.is to those plans.

• Take away Take away medication, weapons medication, weapons etc in the department.etc in the department.

Suicide RisksSuicide Risks

• High riskHigh risk– OlderOlder– MalesMales– Living aloneLiving alone– Physically illPhysically ill– DepressedDepressed– SchizophrenicSchizophrenic– h/o substance abuseh/o substance abuse– Prior attemptsPrior attempts

• Low riskLow risk– YoungerYounger– FemalesFemales– No clear/active planNo clear/active plan– Gesturing behaviorGesturing behavior– Strong social Strong social

support and follow support and follow upup

• Rate of suicide in the US is about 1% Rate of suicide in the US is about 1% (31,000 deaths/yr)(31,000 deaths/yr)

• Drug overdose most common form of Drug overdose most common form of attemptattempt

Suicide AttemptsSuicide Attempts• Get as much history as possible from all sourcesGet as much history as possible from all sources

• Immediate ABC’s if patient is unstableImmediate ABC’s if patient is unstable

• Remove any items patient may have on them that could be a threat (lighter, pills, knife etc)Remove any items patient may have on them that could be a threat (lighter, pills, knife etc)

• For overdose: get time of ingestion, quantity, strength of substance, what substance(s), any For overdose: get time of ingestion, quantity, strength of substance, what substance(s), any other available substances that are unaccounted for, how much was initially available, when other available substances that are unaccounted for, how much was initially available, when was patient last seen and normalwas patient last seen and normal

• Patient needs a sitterPatient needs a sitter

• Work up as appropriate, but should include cbc, chem 10, urine tox, pregnancy, etoh screen Work up as appropriate, but should include cbc, chem 10, urine tox, pregnancy, etoh screen (gets all alcohols), acetaminophen and salicylate level (gets all alcohols), acetaminophen and salicylate level

• CXR to look for pill fragmentsCXR to look for pill fragments

• EKG to document normal QRS, no arrhythmias or prolonged QTEKG to document normal QRS, no arrhythmias or prolonged QT

• If “found in the garage with car on”, consider Carbon monoxide levelsIf “found in the garage with car on”, consider Carbon monoxide levels

• Anything else that may be deemed necessary based on injuries etc.Anything else that may be deemed necessary based on injuries etc.

DispositionDisposition

• Should be carefully documented and Should be carefully documented and determined with help their mental health determined with help their mental health providerprovider– Contract for safetyContract for safety– Document careful follow up planDocument careful follow up plan– Adequate social supportAdequate social support– Admit those with:Admit those with:

• Active planActive plan• Cannot contractCannot contract• High risk factorsHigh risk factors• Acute psychosisAcute psychosis• High risk attempt (gunshot, hanging, significant High risk attempt (gunshot, hanging, significant

ingestion with lethal substance (tricyclics etc)ingestion with lethal substance (tricyclics etc)• Danger to themselves or others (manic, wreckless, Danger to themselves or others (manic, wreckless,

severe suicide risk)severe suicide risk)

Substance AbuseSubstance Abuse

• Huge problem in the country, and Huge problem in the country, and problem for EMproblem for EM

• Commonly see “want to stop Commonly see “want to stop drinking, or stop using drugs”, drinking, or stop using drugs”,

• But patient may present as an But patient may present as an “found altered and unknown toxin “found altered and unknown toxin suspected”suspected”

““Wants detox”Wants detox”• For UNC the information you need to For UNC the information you need to

know is:know is:•Substances used, and on average how much Substances used, and on average how much

and for how longand for how long

•Last useLast use

•History of withdrawal (DT’s etc)History of withdrawal (DT’s etc)

•Other current medical problems that would Other current medical problems that would need attention (i.e cocaine use, but now need attention (i.e cocaine use, but now having chest pain)having chest pain)

•Psychiatric history including suicidalityPsychiatric history including suicidality

•Are they currently in withdrawal, or getting Are they currently in withdrawal, or getting ready to go into withdrawalready to go into withdrawal

•Can I clear them from a medical standpoint?Can I clear them from a medical standpoint?

DetoxDetox

• Once you have cleared them, you Once you have cleared them, you can either call freedom house (UNC can either call freedom house (UNC specific), or if they are full, then specific), or if they are full, then psych can help dispo (once they are psych can help dispo (once they are clear from a medical standpoint)clear from a medical standpoint)

• May need admission for r/o mi (if May need admission for r/o mi (if active cp and cocaine), or if history active cp and cocaine), or if history of withdrawal seizures from etoh etc.of withdrawal seizures from etoh etc.

Acute Presentation of Acute Presentation of Substance AbuseSubstance Abuse

• ABC’s: check for gag, determine gcs, ?ABC’s: check for gag, determine gcs, ?need for immediate intubationneed for immediate intubation

• History (as with suicide attempts)History (as with suicide attempts)

• Vitals and neurologic status, Vitals and neurologic status, expecially pupil size, diaphoresis, expecially pupil size, diaphoresis, heart rateheart rate

• EKGEKG

• Look for toxidrome patternLook for toxidrome pattern

Approach to patientApproach to patient

• Toxidromes: common patterns of findings Toxidromes: common patterns of findings with specific ingestions (more in the tox with specific ingestions (more in the tox lecture)lecture)

• IV/o2/monitorIV/o2/monitor• Coma Cocktail:Coma Cocktail:

• Thiamine (100mg iv):Thiamine (100mg iv): alcoholics are predisposed to alcoholics are predisposed to thiamine deficiency and may have wernicke-korsakoff’s. thiamine deficiency and may have wernicke-korsakoff’s.

• Dextrose (1amp d50):Dextrose (1amp d50): for any pt with altered mental for any pt with altered mental status, check glucosestatus, check glucose

• Narcan (0.01mg/kg iv):Narcan (0.01mg/kg iv): give to suspected narcotic give to suspected narcotic toxidrome, or severe altered mental statustoxidrome, or severe altered mental status

• Flumazenil:Flumazenil: benzo antagonist, but MANY benzo antagonist, but MANY contraindications and we don’t normally give in the acute contraindications and we don’t normally give in the acute setting.setting.

Differential DiagnosisDifferential Diagnosis

• Organophosphate poisoningOrganophosphate poisoning

• Pontine hemorrhagePontine hemorrhage

• Clonidine overdoseClonidine overdose

Work upWork up

• Basic and tox labsBasic and tox labs• Drug levels (depakote, lithium) if appropriateDrug levels (depakote, lithium) if appropriate• CXRCXR• EKGEKG• Possible head ct/neck ct if trauma is Possible head ct/neck ct if trauma is

suspected or if not a clear “tox” historysuspected or if not a clear “tox” history• Urine tox/pregnancyUrine tox/pregnancy• Cardiac labs if cocaine and chest pain, or if Cardiac labs if cocaine and chest pain, or if

you cannot determine chest painyou cannot determine chest pain

Opiates/Narcotics Opiates/Narcotics (heroin/fentanyl)(heroin/fentanyl)

• Death from respiratory depressionDeath from respiratory depression

• Sx: depressed mental statusSx: depressed mental status

• PE:PE:– LethargyLethargy– Pinpoint pupilsPinpoint pupils– Decreased respiratory driveDecreased respiratory drive

• Evaluation: ***responds to Evaluation: ***responds to Narcan Narcan (can give (can give every 2-3 minutes, little bit at the time until every 2-3 minutes, little bit at the time until max of 10 mg or mental status returnsmax of 10 mg or mental status returns

• Admit: persistently altered, or drugs with long Admit: persistently altered, or drugs with long half life (methadone)half life (methadone)

Amphetamines/CocaineAmphetamines/Cocaine

• Death from: mi, arrhythmias, cva, Death from: mi, arrhythmias, cva, hyperthermia, renal failurehyperthermia, renal failure

• All sympathomimeticsAll sympathomimetics

• Sx: euphoric, anxious, agitated, paranoid, Sx: euphoric, anxious, agitated, paranoid, “chest pain”“chest pain”

• Neuro findings:Neuro findings:– SeizureSeizure– Focal findings (weakness)Focal findings (weakness)– ““wash-out”- decreased ms, lethargy, wash-out”- decreased ms, lethargy,

drowsiness with chronic use, or after prolonged drowsiness with chronic use, or after prolonged bingingbinging

Cardiopulmonary FindingsCardiopulmonary Findings

• Dysrhythymias, hypo or Dysrhythymias, hypo or hypertension, signs of MIhypertension, signs of MI

• Asthma or reactive airway diseaseAsthma or reactive airway disease

• Hyperthermia (> 105.0)Hyperthermia (> 105.0)

• Can get pneumomediastinum from Can get pneumomediastinum from smokingsmoking

pneumomediastinumpneumomediastinum

Air in soft tissuesAnd around the Neck.

Can also sometimesSee air around the heart Border (not in this one)

Differential DiagnosisDifferential Diagnosis

• CNS infectionCNS infection

• PheochromocytomaPheochromocytoma

• Thyroid stormThyroid storm

• VasculitisVasculitis

• hypoglycemiahypoglycemia

Workup and treatmentWorkup and treatment• Abc’s, full labs and cxr, ekg, head ct (if needed)Abc’s, full labs and cxr, ekg, head ct (if needed)

• Benzos (ativanBenzos (ativan etc) for agitation, chest pain etc) for agitation, chest pain

• If evidence of MI: If evidence of MI: give nitrates, heparingive nitrates, heparin, ptca if needed, ptca if needed

• DO NOT GIVE B-BLOCKERSDO NOT GIVE B-BLOCKERS

• Treat hypothermiaTreat hypothermia

• If asymptomatic and no end organ damage, then can If asymptomatic and no end organ damage, then can d/c, but otherwise admit as appropriated/c, but otherwise admit as appropriate

Hallucinogens (LSD, MDA, PCP, Hallucinogens (LSD, MDA, PCP, psilocybin)psilocybin)• Exact mech. Of action unknown, but Exact mech. Of action unknown, but

thought to interact with serotonin and thought to interact with serotonin and dopamine mechanisms in the CNS.dopamine mechanisms in the CNS.

• Death: from activities associated with Death: from activities associated with concurrent use (driving etc)concurrent use (driving etc)

• Sx:Sx:– Euphoria, hallucinationsEuphoria, hallucinations– Bad trip: paranoia, anxiety, unusual thought Bad trip: paranoia, anxiety, unusual thought

processprocess– Most have “sense of self” except with PCPMost have “sense of self” except with PCP

Signs of HallucinogensSigns of Hallucinogens

• Hyperthermia (associated with some)Hyperthermia (associated with some)

• Anticholinergic effectsAnticholinergic effects– Dry mouthDry mouth– Dialated pupilsDialated pupils– TachycardiaTachycardia– FlushingFlushing– delirumdelirum

Differential DiagnosisDifferential Diagnosis

• Acute psychosisAcute psychosis

• Conversion disorderConversion disorder

• EncephalitisEncephalitis

• NeurosyphillisNeurosyphillis

• DementiaDementia

Evaluation/therapy/dispoEvaluation/therapy/dispo

• Often don’t show up on utoxOften don’t show up on utox

• Standard labs, check CK if suspect Standard labs, check CK if suspect possible rhabdomyolisispossible rhabdomyolisis

• Reassurance and Reassurance and BenzosBenzos for for agitation prnagitation prn

• d/c if asymptomatic at 4-6 hoursd/c if asymptomatic at 4-6 hours

Toxic alcoholsToxic alcohols

• Will discuss in tox lectureWill discuss in tox lecture

THE ENDTHE END