Neuropsychiatric Emergencies Andy Jagoda, MD, FACEP Professor of Emergency Medicine Mount Sinai Scho

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Neuropsychiatric Emergencies Andy Jagoda,
MD, FACEPProfessor of Emergency MedicineMount
Sinai School of MedicineNew York, New York
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The Case

• 26 year old female presents to the ED with a
  chief complaint of acting strange
• According to her husband, for the past 24 hours
  she has been having periods of fear and paranoia
  
• PMH none Tob none
• Medications none ETOH none
• Drugs none LNMP s/p abortion 2 day prior

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The Case

• Vital Signs 150/90 110 18 100
• Blood Sugar 120 mg / dL
• Patient is extremely agitated, fearful, and
  uncooperative
• Pupils equal and reactive to light
• Moving all four extremities
• Patient was triaged to the Psychiatric Emergency
  Department

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The Questions

• What per cent of patients triaged to the
  psychiatric ED have an underlying medical
  condition causing their acute complaint?
• What constitutes medical clearance?
• What is delirium?
• What strategies are available to manage the
  agitated / violent patient?

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Psychiatrists should be able to medically
evaluate their own patients by performing a
complete history and physical examination?True
False
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Emergency physicians should be able to
competently evaluate the psychiatric and
neurologic mental status of their
patientsTrue False
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Background

• 105 million ED visits a year in the USA
• 2 to 12 of patients presenting to the ED have a
  psychiatric complaint
• 25 to 50 of patients with psychiatric illness
  also have a medical disorder that can contribute
  to acute disturbances in thought, behavior, mood,
  or social relationships
• 4 to 12 of psych inpatients have a medical
  condition identified as precipitating the
  admission

Tintinalli et al. Ann Emerg Med 1994
23859 Dolan et al. Arch Intern Med 1985 145
2085
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Challenges to overcome caring for the patient
with a psychiatric complaint

• Bias against patients with mental illness
• Prioritization of sicker patients
• Patient unwilling or unable to cooperate
• Time constraints

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McIntyre JA, Romano J Is there a stethoscope in
the house (and is it used?). Arch Gen Psych 1977
34114787 of surveyed psychiatrists did not
routinely perform a physical examination on their
inpatientsPatterson C. Psychiatrists and
physical examinations A survey. Am J Psych 1978
13596783 of psychiatrists did not routinely
perform physical examinations on their
inpatients. Reasons - uncomfortable performing
an exam- already performed by someone else, -
desire to avoid transference / countertransference
- dislike of performing medical examinations
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Riba M Medical clearance Fact or fiction in the
hospital emergency room. Psychosomatics 1990
31 400-404

• Retrospective chart review of 137 ED patients
  with psychiatric diagnoses
• 32 no vital signs
• 64 no documentation of general appearance
• 67 no documentation of present illness
• 92 no neurologic examination
• 92 no laboratory testing

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Tintinalli J et al. Emergency medical evaluation
of psych patients. Ann Emerg Med 1994 234
859-862

• Retrospective review, 298 charts of patients with
  psychiatric chief complaint
• 12 (4) required acute medical tx within 24 hours
  of admission 10 (3) were transferred to a
  medical service
• Neuro exam, including mental status, was most
  frequent deficiency
• Younger patients had a four fold greater risk of
  having a missed medical diagnosis

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General Approach to Medical Clearance

• Triage based on chief complaint and vital signs
• History
• Physical
• Laboratory testing

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Findings Suggestive of an Underlying Medical
Disorder for Psychiatric Symptoms

• Onset after age 40 / No past history of
  psychiatric illness
• Sudden onset
• Presence of a toxidrome
• Visual hallucinations
• Known systemic disease
• New medication
• Abnormal vital signs
• Disorientation / Clouded consciousness

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The History

• Baseline mental and physical status prior to
  psychiatric history
• Good listeners and patient advocates have the
  best chance of getting an appropriate history
• Involve family, friends, others
• Time and rapidity of onset
• Medications and / or changes in dosing
• Alcohol and / or illicit drug use
• Why now conceptual framework to understand
  what overwhelmed usual coping mechanisms

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The Physical

• Vital signs accurate temp, pulse oximetry
• Appearance
• Head exam signs of trauma
• Neck exam thyroid, meningeal signs
• Cardiovascular
• Abdomen
• Neuro exam
• Mental status (cognition)
• CN with a focus on II, III, IV, and VI
• DTRs
• Motor muscle wasting, tone, automatisms
• sensory
• cerebellar

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Mini-Mental Status Examination (Cognition)

• Orientation
• Attention
• Registration / Recall (memory)
• Language (repetition / naming)
• Visual Spatial

• O x 3
• Could not give months
• Could repeat but could not recall 3 objects
• Intact
• Intact

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The Psychiatric Mental Status Exam

• Appearance
• Motor
• Speech
• Affect and mood
• Thought content
• Thought process
• Perception
• Insight / Judgement
• Impulse control / safety

• Disheveled
• Normal
• Normal
• Flat
• Paranoid, No suicidal ideation
• Concrete
• No hallucinations
• No insight into her illness
• Did not feel out of control

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Laboratory Testing

• Hall et al. Unrecognized physical illness
  prompting psychiatric admission A prospective
  study. Am J Psych 1981 138629
• 100 state hospital psych patients with no known
  medical disease or substance abuse
• SMA-34, urine tox, EEG
• 60/100 had an abnormality on the SMA-34
• Did not address how many of the abnormalities
  were clinically significant

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Laboratory Testing

• Henneman et al. Prospective evaluation of ED
  medical clearance. Ann Emerg Med 1994 24 672
• 100 ED patients with new psychiatric complaints
• HP, ETOH, urine tox, CBC, SMA 7 CT optional, LP
  if febrile
• Excluded known patients with psych disorders,
  psych patients with medical complaints, known
  drug use or suicide attempt
• 63/100 had medical cause identified 30/63 tox,
  25/63 neurologic, 5/63 infectious (3 CNS)

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Laboratory Testing

• Olshaker et al. Medical clearance and screening
  of psychiatric patients in the ED. 19972124
• 345 patients for medical clearance
• 65 (19) found to have a medical condition
• History 94 sensitivity laboratory testing 20
  sensitive
• Conclude that HP is the most important part
  medical clearance and laboratory testing is low
  yield

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Summary on Medical Clearance

• A complete history and physical is key to
  medical clearance
• Laboratory testing is driven by the HP
• Consider laboratory testing
• Underlying medical condition
• Abnormal vital signs
• Elderly
• New onset psychiatric complaint

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Medical Screen vs Medical Evaluation

• Medical screen establishes that the patient is
  currently stable vs Medical evaluation
  establishes patients baseline state of health
• Drug of abuse screen screen may help in the
  psychiatric evaluation and disposition planning
• Liver function and renal function may help in the
  long term treatment planning
• Many inpatient facilities do not have ready
  access to these tests
• Atypical antipsychotics may increase serum
  glucose and lipid levels baseline required
  before initiating therapy
• ECG necessary to evaluate the QT interval

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The Case Continued

• ROS (by husband) 10 lb weight loss over past 6
  months, occasional palpitations, periods of
  agitation / fear, withdrawn behavior, lack of
  initiative, poor hygiene
• General Appearance 30 yo female, disheveled,
  agitated
• Hypervigilant with paranoid ideation that her
  husband was trying to poison her
• Rest of exam was normal including normal thyroid,
  no heart murmur, normal GYN exam, normal skin and
  hair

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Delirium Definition

• Acute, reversible, diffuse neuronal dysfunction
  usually due to a toxic-metabolic derangement
• Characterized by
• Inattention
• Disorientation
• Agitation and/or somnolence
• Hallucinations
• Paranoid ideations

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Confusion Assessment Method (CAM
Score)DeliriumMust have feature 1 and 2 and 3
or 4

• Feature 1 Acute onset and fluctuating course
• History by family
• Change from the baseline
• Feature 2 Inattention
• Feature 3 Disorganized thinking
• Feature 4 Altered level of consciousness
• Alert, normal
• Vigilant-hyperalert
• Lethargic
• Difficult to arouse

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Delirium Differential Diagnosis

• Structural CNS lesion
• Toxic Overdose vs drug effect
• Withdrawal syndrome
• Metabolic
• Infection Central vs systemic
• Seizure
• Acute psychiatric disorder

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Delirium Physical Examination

• Abnormal vital signs, inattention, flucuating
  course
• Toxidromes
• Cholinergic, anticholinergic, adrenergic, opioid,
  hallucinogen, sedative
• Focal neurologic findings
• Evidence of systemic disease
• Dehydration, hypoxia, liver / renal failure,
  CHF, COPD

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Modified Mini-mental Status Exam.(Used to
diagnose cognitive impairment)

• 5 - Time Orientation - date, day, season
• 5 - Place Orientation - City, State, Building
• 5 - Attention - serial 7s, months forward /
  reverse
• 3 - Registration of 3 objects (immediate recall)
• 3 Memory - 3 objects in 3 minutes (delayed
  memory)
• 9 Language / Visual Spatial repeat no ifs
  ands buts, 3 stage command, write sentence, copy
  design
• 23 or less cognitive abnormality

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Hustey. ED Prevalence and Documentation of
Impaired Mental Status in Elderly. Ann Emerg Med
2002 39

• 26 (78/297) of patients had altered ms
• 10 (30/297) had delirium
• 17/30 (57) had documentation of abnormal mental
  status by ED provider
• 70 of pts discharged home with cognitive
  impairment had no evidence available that the
  mental status abnormality was chronic

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Delirium Laboratory Work-up

• CBC / Metabolic panel
• LFTs
• Toxicology Screen
• Brain imaging / LP
• Blood cultures if sepsis suspected
• EEG in select patients

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Case Continued

• The patient was diagnosed having acute delirium
  with psychosis.
• CBC, SMA 9, LFTs, tox screen were normal
• A CT was ordered but the patient was too agitated
  too cooperate

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Interventions for the Agitated Patient

• Interview considerations
• Environmental factors
• Chemical control
• Physical restraints

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Interview Considerations

• Calm and Direct
• Empathic
• Verbalize limits / expectations
• Consistency among staff

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Interview Techniques

• Eye Contact
• Personal Space
• Door Position
• Body Language

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Environmental Factors

• Secure / private
• Quiet
• Weapons detection

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Medications

• Benzodiazepines
• Typical Antipsychotics
• Haloperidol
• Droperidol
• Antispychotic plus Benzodiazepine
• Atypical antipsychotic

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Benzodiazapines

• Lorazepam, diazepam, midazolam
• Anxiolitics not antipsychotics
• Less predictable effect
• Paradoxical disinhibition
• Less titratability
• Risk of cardiorespiratory depression

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Haloperidol

• Butyrophenone antipsychotic
• 5- 10 mg IM, PO, IV
• Onset 20 minutes
• t1/2 19 hours
• Side Effects
• Dystonic Reaction
• Akathesia
• Neuroleptic Malignant Syndrome
• Cardiovascular Effects Torsades (.4)
• Seizure Threshold

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Droperidol

• Butyrophenone antipsychotic
• 2.5- 5 mg IM or IV
• Onset minutes
• t 1/2 2-4 hours
• Side effects
• Dystonic reaction
• Akathesia
• Neuroleptic Malignant Syndrome
• Cardiovascular effects Torsades
• Seizure threshold

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The Droperidol Dilemma

• Lancet 2000 Droperidol reported to cause QT
  prolongation and possibly sudden death Janssen
  withdrew drug from the European market
• Patients self administered large doses
• Often used with other antipsychotics
• FDA 2001 Black box warning Dear Health Care
  Professional . . .
• Recommended that it not be given to males with a
  QTc gt440 and females with a QTc gt450

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The Droperidol Dilemma

• Acad Emerg Med 2002. Behind the black box
  warning
• The FDA data analyzed 93 cases of death
  identified
• 52 cases at doses gt 10 mg (most 50-100 mg IM)
• 22 cases, no dose given
• 11 cases of torsades 9 cases of prolonged QTc
• 13 cases of death at doses below 10 mg
• 3 involved multiple doses
• 3 were anesthetic related
• 1 case the dose was .635 mg
• 1 case the dose was .25 mg
• 5 potential cases out of the original 93

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Atypical Antipsychotics

• e.g. Respiridone
• Orally administered with or without a
  benzodiazepine
• May prolong the QTc
• Role still undefined

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AAP. Practice guideline for the treatment of
patients with delirium. Am J Psychiatry 1999 156
(suppl)1-20

• Monotherapy with a typical antipsychotic
  haloperidol or droperidol
• Droperidol has a faster onset and less frequent
  need for a second dose
• Need to monitor ECG and serum Mg levels
• Benzodiazepines as a monotherapy is reserved for
  delirium from drug withdrawal
• Generally avoided as monotherapy in the elderly
• Lorazepam possibly preferred in patients with
  liver disease
• Combined therapy of a antipsychotic plus a
  benzodiazepine may have faster onset of action
  with fewer side effects

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Physical Restraints

• For imminent threat of harm
• Preparations
• Overwhelming show of force
• Initiate only when prepared
• Preparation / de-escalation

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Physical Restraint

• Once initiated, swift and definitive
• Suspend negotiations
• Team leader
• Secure large joints
• Constant reassurance

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Monitoring

• Documentation
• Neurovascular
• Cardiovascular
• Airway
• Plan for reassessment and removal

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Case Continued

• The patient was sedated with droperidol, 5 mg /
  lorazepam 2 mg IV
• CT was negative
• She was admitted to the Medicine Service
• Blood and urine cultures negative
• Thyroid Function Tests negative
• EEG normal
• Final Diagnosis _________________________________

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Schizophrenia

• Psychotic disorder manifested by one or more
  active phase symptoms, marked social and or
  occupational dysfunction, and a course lasting at
  least 6 months.
• It is a diagnosis of exclusion.
• Positive symptoms include delusions,
  hallucinations, disorganization, and catatonia.
• Negative symptoms include affective flattening,
  inappropriate affect, alogia, avolition,
  asocialtiy, anhedonia, lack of insight, lack of
  initiative, poor hygiene

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Schizophrenia

• Average age of onset for women is 27
• Three phases
• Prodrome attenuated positive / negative symptoms
• Active emergence of active phase symptoms. May
  follow an acute stressor
• Residual phase Attenuated positive / negative
  symptoms. Relapse may occur

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Schizophrenia

• Patient was transferred to the inpatient
  psychiatry service
• Respiridone, 1 mg bid started and increased to 2
  mg bid
• Discharged after 3 weeks, stable with control of
  symptoms
• Stopped taking medication after 3 months
  secondary to weight gain and sexual dysfunction
• Represented to the ED six months after discharge
  with same symptoms

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Conclusions

• Patients with an acute change in behavior require
  a careful medical evaluation
• Historical and physical findings provide the
  baseline necessary to determine diagnostic
  testing
• Delirium is a medical emergency
• In general, antipsychotics are still the
  pharmacologic intervention of choice in the
  acutely agitated patient