Behavioral Emergencies

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Behavioral Emergencies

• PARAMEDIC PROGRAM
• P. Andrews
• Summer 07

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Strange But True
A 28-year old male was brought into the ER after
an attempted suicide. The man had swallowed
several nitroglycerin pills and a fifth of vodka.
When asked about the bruises about his head and
chest, he said that they were from him ramming
himself into the wall in an attempt to make the
nitroglycerin explode.
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Whats this all about?

• Is it normal or abnormal?
• Prevalence?
• Pathophysiology of behavioral and psychiatric
  disorders
• Factors that alter behavior or emotional status
• Medical legal considerations
• Overt behaviors associated with behavioral and
  psychiatric disorders

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• Verbal techniques useful in mgmt of the
  emotionally disturbed pt.
• Appropriate safety measures
• When should family, etc be removed from premises?
• Techniques for physical assessment
• When are you expected to transport a patient
  against his/her will?
• To restrain or not?

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Terms

• Affect
• Anger
• Anxiety
• Confusion
• Depression
• Fear
• Mental status
• Open-ended questions
• Posture
• Post-traumatic stress syndrome
• Psychogenic amnesia
• Schizophrenia

• Bereavement
• Biological/organic
• Bipolar disorder
• Catatonia
• Delirium
• Delusions
• Dementia
• Flat affect
• Manic
• Multiple personality disorder
• Phobia
• Positional asphyxia

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Behavioral and Psychiatric Emergencies

• Not clear cut
• They require a complete history, exam, and
  careful/skilled approach
• Most of what you do will depend on your people
  skills
• Behavioral emergency
• Behavior is so unusual, bizarre, threatening or
  dangerous possibly life-threatening to self or
  others

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What is normal, anyway???

• Determined by
• Culture
• Ethnic groups
• Socioeconomic class
• Personal interpretation, opinion
• Does it
• Interfere with core life functions?
• Pose a threat to the life or well-being of the
  patient or others?
• Significantly deviate from societys
  expectations?
• Normal ? Behavior that is readily acceptable in
  a society!

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Pathophysiology

• 20 of population has some type of mental
  health problem
• 1 in 7 will require treatment
• Anxiety
• Depression
• Eating disorders
• Mild personality disorders
• Behavioral and psychiatric disorders incapacitate
  more people than all other health problems
  combined!

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True/not true?

• All mental patients are unstable and dangerous
• Their conditions are incurable

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Biological causes

• Alcohol
• Drugs (including OTC, Rx)
• Infection
• Tumors

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Potential Organic Causes
Frontal atrophy from Alzheimers disease
Brain neoplasm
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Psychosocial

• Personality style
• Dynamics of unresolved conflict
• Crisis management methods
• Environment
• Traumatic childhood incidents

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Sociocultural

• Situational
• Relationships
• Support systems
• Social isolation
• Rape/assault
• Witnessing acts of violence
• Loss of a job
• Ongoing prejudice or discrimination

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Assessment of behavioral patients

• The same as for all other patients
• Scene size-up look for hazards
• Initial assessment watch posture body
  language
• Focused history
• Physical examination
• You begin your care at the same time good
  interpersonal skills, remember?

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More about the H E

• Listen open-ended questions
• Pay attention
• Spend time
• Be assured
• Do not threaten
• Let there be silence
• Place yourself at their level
• Keep a safe proper distance
• Appear comfortable
• Dont judge
• Never lie

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Mental status examination

• General appearance
• Behavioral observations verbal and non-verbal
  behavior
• Orientation
• Memory
• Sensorium is pt. Focused, paying attention?
• Perceptual processes thought patterns ordered?
• Mood and affect
• Intelligence
• Thought processes
• Insight
• Judgment
• psychomotor

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Form a general impression
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Dementia

• 25 50 over 85 y/o have dementia
• Alzheimers most common
• Mini-strokes
• Affected person sometimes recognizes first signs
• Keys?
• Lost while driving, etc
• Common tasks
• Difficulty with words
• Time between first symptoms death 7 10 years

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Dementia

• Affect
• Normal or flat, depending on stage of condition
• Aphasia
• Impaired communication
• Apraxia
• Impaired motor activities
• Agnosia
• Failure to recognize objects
• Disturbance in executive functioning
• Impaired ability to plan, organize or sequence

• Gradual impairment of memory and cognitive
  functions
• Forgetfulness
• Failure to recognize objects or stimuli
• Orientation
• Excellent recall of past history
• May not remember current events

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• Causes
• Alzheimers disease
• AIDS
• Parkinsons disease
• Vascular disease
• Head trauma
• Substance abuse

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Dementia and Delirium

• Delirium may occur in dementia patients
• Delirium Presentation
• Rapid onset (hours or days)
• Inattention, disorientation, memory impairment
  and visual hallucinations
• Causes of delirium are usually reversible
• Rule out acute medical problems, medication
  changes

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Treatment

• Supportive
• Meds
• Aricept
• Cognex

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Schizophrenia

• Gross distortions of reality
• Preoccupation with inner fantasies
• Withdrawal from social interaction
• Disorganization of thoughts, perceptions, and
  emotions
• Behavior linked with medication noncompliance
• Chronic substance abuse in teenage years linked
  to development of the disease

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Schizophrenia Symptoms

• Disorganized behavior/dress
• Flat affect
• Disorganized speech
• Incoherent or frequently veers off track
• Delusions
• Hallucinations
• Often auditory sometimes visual
• Motor Movements
• May act upon hallucinations

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Profiles of Schizophrenic Behavior

• Delusional
• A man who wraps his house in tin foil to divert
  the rays from FBI satellites.
• Paranoid
• The man introduces himself as Jesus Christ and
  tells you that the city council is out to crucify
  him.

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Profiles of Schizophrenic Behavior

• Disorganized (interview with a physician)
• S____t on you all who rip into my internals! The
  grudgerometer will take care of you all! I am
  the Queen, see my magic, I shall turn you all
  into sidgelings forever!

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Profiles of Schizophrenic Behavior

• Undifferentiated
• Magical thinking
• Creates new words or cryptic language
• Cannot reason abstractly

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Diagnosis of Schizophrenia

• Two or more symptoms must each be present for a
  significant portion of each month over the course
  of 6 months.
• Sx must cause a social or occupational
  dysfunction
• Most schizophrenics are diagnosed in early
  adulthood

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Approach to a schizophrenic pt.

• Be supportive
• Be nonjudgmental
• Dont reinforce the patients hallucinations
  but know that he considers them real
• Speak openly and honestly
• Be encouraging and realistic
• Be alert for aggressive behavior
• Restrain pt if necessary

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Anxiety Disorders

• Panic Attacks
• Acute, unprovoked episodes
• Last approximately 1 hour
• Symptoms
• Cardiac chest pain, nausea
• Dyspnea or a sense of feeling smothered
• Fear of going crazy
• Paresthesia, dizziness
• Trembling, shaking

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Mood Disorders Mania

• Sudden onset with rapid progression of symptoms
  (days)
• Presentation
• Progressive inflation of self-esteem
• Distracted, racing thoughts
• Delusions may occur
• Very talkative with rapid speech
• Excessive involvement in high pleasure/high risk
  activities

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Management for anxiety disorder

• Simple, supportive
• Be empathetic
• Assess medical complaints tx prn
• Consider sedative
• Valium
• Versed
• Ativan
• Benadryl

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Bipolar disorder

• One or more manic episodes with or without
  depression, lasting at least one week
• Not common
• Episodes often begin suddenly and escalate
  rapidly
• Disorder usually develops in adolescence or early
  adulthood

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The Stages of Mania

• Excessive involvement in pleasurable activities
  with high potential for consequences

• Mild
• On top of the world
• Egocentric
• Decreased need for sleep
• Severe elation
• Rapid speech
• Illogical associations
• Delusions of grandeur

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Mood Disorders Depression

• Situational v. persistent
• Lack of interest in daily activities
• Altered mood impairs daily functioning
• May be present with other disorders
• Bipolar disease
• Substance abuse

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Presentation of Depression

• Bizarre behavior usually not seen in depression
• Inability to see beyond the persons immediate
  situation
• Lethargy, slow thought process and speech
• Stooped posture
• Poor appearance

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General Management Considerations

• Behavioral crisis development and management are
  viewed as a spectrum
• Patients do not suddenly develop anger or
  passivity
• Use the scene dynamics wisely to effect patient
  cooperation
• Never leave depressed or suicidal patient alone

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• Assess situation
• Protect self and others
• Summon law enforcement if necessary
• If no evidence of immediate danger, then one EMT
  responsible for assessing, treating and
  communicating with patient
• Transport with consent (when possible) without
  sirens

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The Spectrum
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When is it time for patient restraint?
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• Use only when necessary
•           Patient is a danger to themselves or
  others
•           Look for all possible causes for the
  behavior
•           Restraints must allow for adequate
  monitoring of vital signs
•           Restraints applied by law enforcement
  must allow sufficient slack
•          

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• Patient must be able to straighten the abdomen
  and chest and take full breaths
• The officer must accompany the patient in the
  ambulance
• Approved equipment for prehospital personnel
• Padded leather
• Soft restraints (posey, velcro, seatbelts)
•          

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Unapproved methods of restraint for prehospital
personnel

• Hard plastic ties or device that requires a key
  to remove
• Backboard, scoop, or flat used to sandwich the
  patient
• Hog - tied (hands and feet behind the patient)
• Methods or material that could cause
  neurovascular compromise
• Evaluate and document the condition of the
  restrained extremity (neurovascular check) every
  15 minutes.

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Documentation of Restraint Application

• Reason the restraints were needed         
• Which agency applied the restraints         
• Information and data regarding the monitoring of
  circulation to the restrained extremity         
  
• Information and data regarding the monitoring of
  respiratory status while restrained

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Somatoform disorders

• Somatization disorder
• Pt is preoccupied with physical symptoms
• Conversion disorder
• Loss of function (blindness, paralysis)
• Hypochondriasis
• Exaggerated interpretation of physical symptoms

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Neurotransmitters and Behavior
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Neurotransmitters Norepi

• Promotes awakening and enhances dreams
• Elevates mood
• CNS locations cortex, medulla, hypothalamus,
  limbic system, cerebellum
• NE locations outside the CNS
• Mania and delusions with overstimulation
• Depression with low levels

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Neurotransmitters Dopamine

• Stimulates emotional responses
• Controls subconscious skeletal movement
• CNS locations cerebral cortex, hypothalamus and
  limbic system
• Schizophrenia and schizoid symptoms from
  amphetamines

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Neurotransmitters Serotonin

• Controls sleep, sensory perception, mood control
• Thermal regulation
• CNS locations hypothalamus, limbic system and
  cerebellum
• Hallucinations with LSD and overstimulation
• Depression and anxiety with low levels

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Neurotransmitters GABA

• Gamma aminobutyric acid
• Depresses mood and emotion
• CNS locations everywhere!
• Enhanced by benzodiazepines
• Anxiety from low levels of GABA

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Neurotransmitters and Drug Therapy
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Top prescribed Rx for 2004

• 6 Zoloft (SSRI)
• 9 Zyprexa (Antipsychotic)
• 13 Effexor XR (SSRI)
• 18 Risperdal (Antipsychotic)
• 19 Seroquel (Antipsychotic)

• 23 Ambien
• 47 Welbutrin (SSRI)
• 53 Ablify (Antipsychotic)
• 58 Paxil (SSRI)
• 69 Adderall (Amphetamine)

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Additional Top Rx - 2003

• Alprazolam
• Lorazepam
• Clonazepam
• Wellbutrin
• Amitryptiline

• Trazadone
• Diazepam
• Temazepam
• Remeron (Serotonin stimulant)
• Concerta (amphetamine)

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Drug Therapies Antipsychotics

• Phenothiazines and their derivatives
• Mellaril, Navane, risperidone, thorazine,
  stelazine, Prolixin
• Dopamine blockade
• Will produce a flatter affect
• Suppress hallucinations and delusions
• Side effects hypotension, dystonic reactions

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Drug Therapies Lithium

• Metallic compound
• Slows the elevated use of serotonin, NE and
  dopamine in the synapse
• Slows sodium transport into the cell and reduces
  nerve transmission
• Effective for chronic control of mania
• In mania, sodium transport occurs 200 more than
  normal!

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Drug Therapies TCA, MAOI

• Both work to keep norepinephrine in the synapse
  longer
• Elevates activity and mood in depression
• Anticholinergic effects
• Overdose
• Initially, massive amounts of NE released
• Lack of reabsorption drops functional NE levels
  dramatically
• Systemic effects!

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Drug Therapies SSRI

• Keeps serotonin in the synapse
• Prozac, Paxil, Zoloft
• Overdose symptoms typically limited

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Serotonin Syndrome

• Medications that work in similar areas as SSRIs
• TCAs and MAOIs
• Tramadol (narcotic)
• Meprobamate (Sedative-hypnotic)
• Promethazine
• Intense potentiation of SSRI effects

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Medical causes of behavioral crises
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Clues suggestive of a potential medical cause of
the behavior

• Abnormal vital signs
• Depressed level of consciousness
• Obtunded
• Evidence of drug or toxin ingestion
• Very sudden onset of symptoms
• Focal neurological signs
• No previous psychiatric history
• Presence of specific physical symptoms

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A 24 year-old female was seen for manic-type
symptoms. She had irritability, rapid speech and
distracted conversation. These symptoms had
progressed over a 1-week period. She had no
history of mental illness or drug intoxication.
Lab tests revealed a markedly high T4 level and
she was diagnosed with thyrotoxicosis.
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A 28 year-old female with a history of bipolar
disorder was experiencing significant withdrawal
and depression. She was apathetic with a flat
affect and did not seem to interact with things
around her. An hour after admission, she was
lethargic, nonresponsive and hypotensive. Lab
tests revealed lithium toxicity.
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A 20 year-old was talking incoherently, picking
at her clothes and staring into space. After she
was admitted to the hospital, her level of
consciousness rapidly deteriorated, becoming
disoriented and less responsive. She had no
history of psychiatric disease or drug use. Her
only history was that of herpes zoster.
After an EEG and lumbar puncture, she was
diagnosed with encephalopathy.
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Suicide

• 9th leading cause of death overall
• 3rd leading cause of death in 15-24 age group
• Women attempt suicide more often, but men are
  more often successful

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Assessing potentially suicidal patients

• Perform appropriate H E
• Provide appropriate psychological care
• Document observations, especially any detailed
  plans

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Risk factors for suicide

• Previous attempts
• Depression
• Age (15-24, gt40)
• Alcohol or drug abuse
• Divorced or widowed
• Giving away personal belongings
• Living alone/increased isolation
• Psychosis with depression
• Major separation trauma
• Major physical stresses

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Risk factors, cont.

• Loss of independence
• Lack of goals plans for future
• Suicide of same-sexed parent
• Expression of a plan for suicide
• Possession of mechanism for suicide (gun, rope,
  pills)

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Age-related conditions

• Geriatrics
• You may mistake depression for dementia
• Assess their ability to communicate
• Provide reassurance
• Compensate for vision, hearing loss
• Treat with respect
• Avoid administering medication if possible
• Take your time
• Allow family friends to be with patient

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• Pediatrics
• Avoid separating young child from parent
• Make all explanations brief and simple repeat
  often
• Be calm, speak slowly
• ID yourself
• Be truthful
• Encourage child to help with his care
• Dont discourage child from crying, showing
  emotion
• Allow child to keep favorite blanket or toy

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• Peds, cont.
• Dont leave child alone, even for short period
• If you must be separated from child, introduce
  care giver who will take over

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Management of Sudden Death Situations

• Resuscitate patient unless obviously dead
• Keep family informed        
• Be truthful        
• Avoid trite phrases       
• Do not offer false hope       
• Empathize/sympathize         
• Allow emotional response  
• Maintain professionalism

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Management of terminally ill

• Do not isolate the family
• Allow feelings to be expressed
• Provide for patients physical comfort
• Allow for patients dignity in dying process
• Resuscitate according to local protocol
  regardless of a living will

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Grief

• Many different reactions
• Cultural differences
• Denial
• Anger
• Bargaining
• Depression
• Acceptance

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How you doin?

• Helplessness/Guilt
• Anger/Frustration
• Avoidance
• Nightmares
• Gallows humor
• Physiological response

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Can you cope?

• Rest
• Exercise
• Humor
• Hobbies
• Have a life outside of EMS
• Talk!
• Others?