Evidence Based Evaluation of Psychiatric Patients

1
Evidence Based Evaluation of Psychiatric Patients

• Stephen J. Traub, MD
• Division of Toxicology
• Department of Emergency Medicine
• Beth Israel Deaconess Medical Center
• Instructor in Medicine
• Harvard Medical School
• Boston, Massachusetts, USA
• Leslie S Zun, MD, MBA, FAAEM
• Chairman and Professor
• Department of Emergency Medicine
• Chicago Medical School and Mount Sinai Hospital
• Chicago, Illinois

2
Learning Objectives

• Become familiar with drug induced altered mental
  status
• Understand the medical clearance process
• Review the evidence that applies to the medical
  clearance process
• Use of adjuncts in the evaluation and treatment
  of the psychiatric patients

3
Medical ClearancePurpose

• To determine whether serious underlying medical
  illness exists which would render admission to a
  psychiatric facility unsafe or inappropriate.
• To identify medical conditions incidental to the
  psychiatric problem that may need treatment.
• To differentiate organic illnesses from
  functional disorders.
• To determine if the patient is on drugs?

4
Drug-Induced AMS

• Nature of the AMS depends on the drug

5
Drug-Induced AMS

• With psychotic patients, consider
• Sympathomimetics
• Cocaine, amphetamines
• Dissociative agents
• Ketamine, PCP, Dextromethorphan
• Hallucinogens
• LSD, Mushrooms
• Anticholinergics
• Diphenhydramine, Jimson weed
• Sedative/Hypnotic withdrawal
• Alcohol, GHB, Benzodiazepines, Barbiturates

6
How do we sort this out?

• History
• You should be so lucky
• Physical Examination
• Truly the key to assessing these patients
• Laboratory Testing
• MAY HURT MORE THAN IT HELPS
• Dont rely on the tox screen to diagnose

7
History

• Reliable history clinches diagnosis
• Often not available

8
Physical Examination

• The toxicologists best friend
• Physical findings point us towards certain
  classes of toxins
• Use a focused physical examination as a potent
  diagnostic tool

9
Toxidromes

• Toxic Syndromes
• What are we looking for?
• Vital signs
• Thought content and speech patterns
• Pupil findings
• Mucous membranes
• Skin
• Bowel/bladder

10
Vital signs

• Pulse/Blood Pressure/Respiratory Rate
• Increased with most drug-related psychoses
• May be normal with hallucinogen use

11
Thought Content/Speech

• Sympathomimetics
• Expansive, grandiose, hypersexual speech
  pressured
• Dissociative Agents
• Internal preoccupation less verbal
• Hallucinogens
• Seeing things speech pattern usually sedate
• Anticholinergics
• Agitated delerium speech garbled, mouthful of
  marbles
• Sedative/Hypnotic Withdrawal
• Agiated speech preserved until later stages

12
Pupils Size

• Normal
• Hallucinogens
• Dilated
• Sympathomimetics
• Anticholinergics
• Sedative/Hypnotic Withdrawal
• Dissociative agents
• Constricted
• Dissociative agents

13
Pupils Nystagmus

• Horizontal nystagmus with many drugs
• Vertical/Rotatory nystagmus with few
• PCP, Ketamine

14
Mucous Membranes

• Secretions regulated by acetylcholine
• Dry membranes antimuscarinics

15
Skin

• Increased sweating
• Sympathomimetics
• Sedative/hypnotic withdrawal
• Decreased sweating
• Anticholinergic

16
Bowel and bladder function

• Moving bowels/urinating is cholinergic
• Decreased bowel sounds, urinary retention ?
  anticholinergic toxicity

17
What is the evidence?

• Nice, Annals of Emergency Medicine 1988
• 204 consecutive tox screens
• Looking for one of eight different toxidromes
• Successful recognition on clinical grounds
• Nurses 88
• Medical residents 84
• Clinical pharmacists 79

18
Example

• 20 year old college student presents for medical
  clearance after being brought in by EMS. Her
  roommate dialed 911 after finding her psychotic.

19
Example

• No further history available

20
Example

• VS P 130, BP 135/82, RR 14, T 38.8 C
• Thought/Speech Agitated, Mumbling
• Pupils 9 mm/nonreactive no nystagmus
• Mucous Membranes Dry
• Skin Dry
• Bowel Sounds Absent
• Foley Catheter 800 cc urine

21
Diagnosis Benadryl Toxicity

• Received 2.0 mg physostigmine IV
• Normal vital signs and mentation after
  physostigmine

22
Laboratory The Tox screen

• Looks for drug OR METABOLITE
• Cocaine/Benzoylecognine
• Cross reactivities/false positives
• Phenylpropanolamine/Amphetamine
• Dextromethorphan/PCP
• False negatives
• PCP analogs
• LOOK AT PATIENT, NOT TEST

23
What is the data?

• Kellerman, Annals of Emergency Medicine 1987
• 361 cases of suspected adult ingestions
• Significant mangagement changes in 2.5
• Belson, Pediatric Emergency Care 1999
• 158 cases of suspected pediatric ingestions
• Qualitative screens rarely change management
• Schiller, Psychiatric Services 2000
• 392 patients presenting to psychiatric emergency
  services
• Randomized to mandatory vs. discretionary drug
  screen
• No change in disposition or length of inpatient
  stay

24
Evidence Based Adapted from the US preventative
Services Task Force Guide to Clinical Preventive
Services 2nd Ed Baltimore, Williams and Wilkins,
1996.

• Level I randomized controlled trial
• Level II lesser trials
• 1-Controlled trials without randomization
• 2-Cohort or case controlled trials
• 3-Multiple time series with or without
  intervention
• Level III expert opinions
• Not evidence based

25
Medical ClearanceComponents

• History and physical exam
• Mental status examination
• Testing
• Treatment

26
Protocol for the Emergency Medicine Evaluation of
Psychiatric PatientsZun, LS, Leiken, JB,
Scotland, NL et. al A tool for the emergency
medicine evaluation of psychiatric patients
(letter), Am J Emerg Med, 14329-333, 1996.
Level III

• Team of Illinois psychiatrists and emergency
  physicians met to develop a consensus document in
  1995
• Coordinate transfers to a State Operated
  Psychiatric Facility (SOF)
• Psych admission must meet 3 criteria
• Evidence of severe psych illness
• Clinically indicated evaluation of any suspected
  medical illness
• Medical problems, if present, must be
  sufficiently stable to allow safe transport to
  and treatment at the SOF.

27

Sample of Services Provided at SOFs

• Monitor vital signs
• Routine neurological monitoring
• Glucose finger sticks
• Fluid input and output
• Insertion and maintenance of urinary catheters
• Oxygen administration and suction
• Clinical laboratories
• Radiographic procedures
• Intramuscular and subcutaneous injections

28
Consensus Document

• Tool establishes the EP as the decision maker if
  lab tests are clinically indicated
• Observation is the means to determine if the
  presentation is from drugs/alcohol
• May be used for adults and children
• Medical findings may or may not preclude transfer
  to a SOF
• Checklist developed as a transfer document

29

• Medical Clearance Checklist
• Patients name _______ Race ______________
• Date _________________ Date of birth________
• Gender ________________ Institution
  _____________
• Yes No
• 1. Does the patient have new psychiatric
  condition?? ?
• 2. Any history of active medical illness needing
  evaluation? ? ?
• 3. Any abnormal vital signs prior to
  transfer ? ? Temperature gt101oF
• Pulse outside of 50 to 120 beats/min
• Blood pressurelt90 systolic orgt200gt120
  diastolic
• Respiratory rate gt24 breaths/min
• (For a pediatric patient, vital signs indices
  outside the normal range for his/her age and
  sex)
• 4. Any abnormal physical exam (unclothed) ? ?
• a. Absence of significant part of body, eg,
  limb
• b. Acute and chronic trauma (including signs of
  victimization/abuse)
• c. Breath sounds
• d. Cardiac dysrhythmia, murmurs
• e. Skin and vascular signs diaphoresis,
  pallor, cyanosis, edema
• f. Abdominal distention, bowel sounds

30

• g.Neurological with particular focus on
• i. ataxia iv. paralysis
• ii. pupil symmetry, size v. meningeal signs
• iii. nystagmus vi. Reflexes
• 5. Any abnormal mental status indicating medical
  illness such as lethargic, stuporous, comatose,
  spontaneously fluctuating mental status? ? ?
• If no to all of the above questions, no further
  evaluation is necessary. Go to question 9
• If yes to any of the above questions go to
  question 6, tests may be indicated.
• 6. Were any labs done? ? ?
• What lab tests were performed? _____________
  
  
• What were the results? __________________
• Possibility of pregnancy ? ? ?
• What were the results? __________________
• 7. Were X-rays performed? ? ?
• What kind of x-rays performed? ______________
  
  
• What were the results? ___________________

31

• g.Neurological with particular focus on
• i. ataxia iv. paralysis
• ii. pupil symmetry, size v. meningeal signs
• iii. nystagmus vi. Reflexes
• 5. Any abnormal mental status indicating medical
  illness such as lethargic, stuporous, comatose,
  spontaneously fluctuating mental status? ? ?
• If no to all of the above questions, no further
  evaluation is necessary. Go to question 9
• If yes to any of the above questions go to
  question 6, tests may be indicated.
• 6. Were any labs done? ? ?
• What lab tests were performed? _____________
  
  
• What were the results? __________________
• Possibility of pregnancy ? ? ?
• What were the results? __________________
• 7. Were X-rays performed? ? ?
• What kind of x-rays performed? ______________
  
  
• What were the results? ___________________

32

• 8. Was there any medical treatment needed by the
  patient prior to medical clearance? ? ?
• What treatment? ___________________________
  
  
• 9. Has the patient been medically cleared in the
  ED? ? ?
• 10. Any acute medical condition that was
  adequately treated in the emergency department
  that allows transfer to a state operated
  psychiatric facility (SOF)? ? ?
• What treatment? __________________
  
• 11. Current medications and last administered?
  _____
• 12. Diagnoses Psychiatric_______________________
• Medical__________________
  ______
• Substance
  abuse_________________
• 13. Medical follow-up or treatment required on
  psych floor or at SOF _
• 14. I have had adequate time to evaluate the
  patient and the patients medical condition is
  sufficiently stable that transfer to ___SOF or
  ___ psych floor does not pose a significant risk
  of deterioration. (check one)
• ____________________________________MD/DO
• Physician Signature 

33
EvaluationMental Status Examination Zun LS and
Gold I A Survey of the form of mental status
examination administered by emergency physicians,
Ann Emerg Med,15 916-922, 1986.

• Random sample of 120 EPs in 1983
• Diagnosis
• head injury 99
• drug ingestion 96
• behavioral complaint 98
• psychiatric abnormality 95
• lt5 minutes to perform the test (72)
• Tests Used
• Level of consciousness 95
• Orientation 87
• Speech 80
• Behavior 76

Level III
34
EvaluationMental Status Examination

• Tests not used
• Handedness 35
• Calculations 36
• Proverbs 38
• New learning ability 42
• Majority perceived a need for and would use a
  short test of mental status (97)
• EPs use selected, unvalidated pieces of a
  standard mental status examination

35
EvaluationShort Mental Status Examinations

• Mini-Mental State Exam
• The Brief Mental Status Examination
• Short Portable Mental Status Questionnaire
• Cognitive Capacity Screening Examination

36
Use of the Short Tests in the EDKaufman, DM, and
Zun, LS A Quantifiable, brief mental status
examination for emergency patients J Emerg Med,
13449-456, 1995.

• Used the Brief Mental Status Examination in an
  inner city ED.
• Score 0-8 normal, 9-19 mildly impaired, 20-28
  severely impaired
• 100 randomly selected subjects
• 100 subjects with indications for the exam
• Chi-squared analysis of the
• physician analysis vs. tool
• 72 sensitivity and 95 specificity in
  identifying impaired individuals in the ED

Level I
37
Brief Mental Status Examination   Item Score
(number of errors) x (weight) total
  What year is it now? 0 or 1 x
4   What month is it? 0 or 1 x
3   Present memory phase after me and remember
it John Brown, 42 Market Street New York   About
what time is it? 0 or 1 x 3 (Answer correct
if within 1 hour)   Count backwards from 20 to
1. 0.1. or 2 x2   Say the months in
reverse 0, 1, or 2 x2   Repeat the memory
phase 0,1,2,3,4 or 5 x2 (each underlined
portion is worth 1 point)   Final score is equal
to the sum of the total(s)   Katzman, R,
Brown, T, Fuld, P, Peck, A, Schechter, R,
Schimmel, H Validation of a short
orientation-memory concentration test of
cognitive impairment. Am J Psych 1983 140734-9.

38
Prospective Medical Clearance of Psychiatric
Patients Leslie Zun, MDRoma Hernandez, MDLouis
Shicker, MDJerold Leikin, MDRandy Thompson, MD

• Purpose
• To demonstrate the accuracy of a protocol for
  medical clearance of psychiatric patients
• To describe the patients who were transferred to
  psych facility
• Submitted for publication

Level II
39
Prospective Medical Clearance Methods

• The protocol was applied to the psych patients
  transferred from an ED to a State Operated
  Psychiatric Faculty (SOF).
• The protocol was applied at four test EDs in the
  city of Chicago that transfers a large number of
  patients to a SOF.
• A medical clearance checklist was developed from
  the protocol to provide a foundation for
  documentation of the medical clearance.
• The checklist was applied prospectively to all
  patients presenting with psychiatric complaints
  from January to July 2001

40
Prospective Medical Clearance Results

• 330 patients who met the criteria, were enrolled
  into the study from the January to June 2001.
• 19.2 had new psychiatric condition
• 13.4 had a hx of medical problems
• 1.5 had abnormal vital signs
• 7.3 had abnormal physical examination.

41

• Related to inadequate initial medical clearance
• No significant difference
• Transfers from SOFs to EDs - January 1, 2000
  through June 30, 2000
• seizures - no dilantin level
• low back pain with h/o trauma
• R/O cellulitis vs. DVT
• Transfers from SOFs to EDs - January 1, 2001
  through June 30, 2001
• intractable pain secondary to chest trauma (Pain
  could not
  
  be managed at SOF)

42
Prospective Medical Clearance Results Test
Performed

• Most frequent test performed
• Number Percentage of total
• Urine tox 109 25.2
• Chemistries 101 23.3
• CBC 97 22.4
• Alcohol 47 10.9
• Urinalysis 30 6.9
• Urine preg 12 3.0
• Accucheck 8 1.8
• EKG 7 1.6

43
Evidence to Test

• 46 of psychiatric patients had unrecognized
  medical illness.
• Hall, RC, Gardner, ER, Popkin, MK, et. al
  Unrecognized physical illness prompting
  psychiatric admission A prospective study. Am J
  Psych 1981 138 629-633.
• 92 of one or more previously undiagnosed
  physical diseases.
• Bunce, DF Jones, R, Badger, LW, Jones, SE
  Medical Illness in psychiatric patients Barriers
  to diagnoses and treatment. South Med J 1982
  75941-944.
• 43 of psychiatric clinic patients had one or
  several physical illnesses.
• Koranyi, E Morbidly and rate of undiagnosed
  physical illness in a psychiatric population.
  Arch Gen Psych 1979 36 414-419.

44
Psych history vs new onset Hennenman, PL,
Mendoza, R, Lewis, RJ Prospective evaluation of
emergency department medical clearance. Ann Emerg
Med 199424672-677.

• 100 consecutive patients aged 16-65 with new
  psychiatric symptoms.
• 63 of 100 had organic etiology for their symptoms
• History (100) 53 ABN 27 sign
• PE (100) 64 ABN 6 sign
• CBC (98) 72 ABN 5 sign
• SMA-7 (100) 73 ABN 10 sign
• Drug
• screen (97) 37 ABN 29 sign
• CT scan (82) 28 ABN 10 sign
• LP (38) 55 ABN 8 sign
• Patients need extensive laboratory and
  radiographic evaluations including CT and LP.

Level II
45
Evidence Not to Test

• Most laboratories, EKG and radiographic testing
  should be abandoned in favor of a more clinically
  driven and cost effective process.
• Allen, MH, Currier, GW Medical assessment in the
  psychiatric emergency service. New Directions in
  Mental Health Services 19998221-28.
• Patients with primary psychiatric complaints with
  other negative findings do not need ancillary
  testing in the ED.
• Korn,CS, Currier, GW, Henderson, SO Medical
  Clearance of psychiatric patients without
  medical complaints in the emergency department. J
  Emerg Med 200018173-176.
• Universal laboratory and toxicologic screening is
  of low yield.
• Olshaker, JS, Browne, B, Jerrard, DA,
  Prendergast, H, Stair, TO Medical clearance and
  screening of psychiatric patients in the
  emergency department. Acad Emerg Med
  19974124-128.

46
Application of a Medical Clearance Protocol
Leslie Zun, MDLaVonne Downey, PhD

• The objective of the study was to determine if
  the use of a medical clearance protocol
• reduces costs for patients presenting with
  behavioral complaints
• reduces the throughput times for these same
  patients.
• Submitted for publication

Level II
47
Protocol Application Methods

• Application of the medical clearance protocol in
  2001 compared to none in 2000.
• The site was an inner, city teaching level I
  Emergency Department with annual volume 44,000.
• The ancillary test costs were obtained from
  billing data and based on 50 of hospital
  charges.
• The throughput time was calculated from the time
  the patient was triaged to the time the patient
  was discharged from the ED.

48
Protocol Application Significance
2000 2001 Significance
Labs 241 161 F10.189, p.002
Radiology 93 167 ns
EKG 120 118 ns
Total 359 219 F7.983, p.006
49
Protocol ApplicationResults

• 2000 - The throughput time ranged from 3.1 hours
  to 24.6 hours with a mean of 9.7 hours.
• 2001 - The throughput time ranged from 2.2 hours
  to 20.0 hours with a mean of 9.0 hours.
• The throughput time was not statistically
  different between the two years (plt.05).
• Use of a medical clearance protocol reduces the
  number and cost of testing (ANOVA F7.894,
  p.006)
•  

50
What needs to be documented?Tintinalli, JE,
Peacodk, FW, Wright, MA Emergency medical
evaluation of psychiatric patients. Ann Emerg Med
1994 23859-862.

• Poor documentation of medical examination of
  psychiatric patients
• 298 charts reviewed in 1991 at one hospital
• Triage deficiencies
• Mental status 56
• Physician deficiencies
• Cranial nerves 45
• Motor function 38
• Extremities 27
• Mental status 20
• medically clear documented in 80

Level II
51
The Term Medically Clear

• Tintinalli states it should be replaced by
  discharge note
• History and physical examination
• Mental status and neurologic exam
• Laboratory results
• Discharge instructions
• Follow up plans
• The term has greater capacity to mislead than to
  inform correctly
• Concern about misdiagnosis, premature referral
  and misunderstandings
• Recommends education and process factors
• Weissberg, M Emergency room clearanceAn
  educational problem. Am J Psych 1979136787-789.
• Medically stable vs. medically clear

52
Treatment

• Physical restraints
• Chemical restraints
• Combination

53
Complications of Patient Restraints Leslie S
Zun, MD, MBA, FAAEMAccepted for publication

• The purpose of the study was to determine the
  type and rate of complications of patients
  restrained in the ED.
• A prospective study for one year of all patients
  who were restrained in a community, inner city
  teaching hospital emergency department.
• The ED nurses or physicians completed a restraint
  study checklist.

Level II
54
Results - Characteristics

• 221 patients were restrained in the ED and
  enrolled in the study from November, 1999 to
  September, 2000.
• The mean age was 36.35 years (range 14-89).
• 71.7 were male.
• 70.9 were African Americans,15.8 Hispanic and
  12.2 Caucasian.

55
Results - Complications

• Complication rate 5.4
• 12 complications
• Getting out of restraints (6)
• Injured others (2)
• Vomiting (1)
• Injured self (1)
• Other (1)
• Hostile or increased agitation (1)
• Aspiration (0)
• Spitting (0)
• Death (0)
• No major complications such as death or
  disability

56
Chemical Restraints

• What are chemical restraints?
• How is it different than treatment?
• What are the indications for chemical restraints?
• What is the appropriate treatment for ED patient
  agitation?

57
What do we know about ED chemical restraints?

• Few good emergency department studies
• Most studies done by psychiatric emergency
  services
• Few comparative trials of different medication or
  combinations
• Current opinion based on consensus documents by
  emergency psychiatrists without emergency
  physicians input
• Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde,
  M, Docherty, JP Treatment of behavioral
  emergencies. Post Grad Med 2001 S1-88.

58
Use of Chemical Restraints

• Diagnosis
• General Medical Etiology
• Substance Intoxication
• Psychiatric Disturbance
• Dosage
• Single dose or multiple doses
• Route and onset
• Oral
• IM
• IV

59
Consumer preferenceHoge, ST, Appelbaum, PS,
Lawlor, T, et. Al A prospective, multicenter
study of patients refusal of antipsychotic
medication. Arch Gen Psych 1990 47949-956.

• Prospective study of the refusal of treatment
  with antipsychotic agents
• Sample of 1434 psychiatric patients at 4 acute
  inpatient units
• 103 of 1434 refused (9.3) oral meds
• Older, higher social class and fewer with
  antiparkinson meds
• Most patients will assent to oral medication
  (gt90)

Level II
60
Use of Chemical Restraints

• Offset
• Sedation
• Safety
• Hypotension
• Dystonic reaction
• Neuroleptic malignant syndrome
• Akathisia
• Respiratory depression
• Increased violent behavior
• Small study demonstrated marked increase in
  violent behavior with high potency (Haloperidol)
  vs low potency neuroleptics (Chlorpromazine).
• Herrera, JN, Sramek, JJ, Costa, JF et al High
  potency neuroleptics and violence in
  schizophrenics. J Nervous Mental Dis 1988
  176558-561.
• Tolerability

61
Choice of Medications

• Use of antipsychotics
• Haloperidol
• Chlorpromazine
• Droperidol
• Loxapine
• Thiothixene
• Molidone
• Use of atypical antipsychotic
• Clozapine
• Risperidone
• Olanzapine
• Ziprasidone

62
Choice of Medications

• Use of benzodiazepines
• Lorazepam
• Flunitrazepam
• Use of combinations
• Haloperidol and Lorazepam
• Risperidone and Lorazepam

63
Problems with Current Medications

• Sedation
• Dystonic reactions
• Hypotension
• Problems with Droperidol
• WARNING
  Cases of QT prolongation and/or
  torsades de pointes have been reported in
  patients receiving INAPSINE at doses at or below
  recommended doses. Some cases have occurred in
  patients with no known risk factors for QT
  prolongation and some cases have been fatal.

64
Choice of Medications New medications

• Ziprasidone (Geodon)
• Oral or IM
• Unrelated to phenothiazine or butyrophenone
• IM is indicated for the treatment of acute
  agitation in schizophrenic patients
• Low incidence of dystonia and hypotension
• Concern about QT prolongation
• Risperidone (Risperdal)
• Oral
• New chemical class
• Indicated for treatment of schizophrenia
• Infrequent dystonia and hypotension

65
Advantages of the New Medications

• Little hypotension
• Less sedation
• Few dystonic reactions
• Replacement for Droperidol?

66
Emergency Psychiatrists SurveyBinder, RL,
McNeal, DE Contemporary practices in managing
acutely violent patients in 20 psychiatric
emergency rooms Psych Services 1999
501553-1556.

• Survey of 20 Psychiatric Medical Directors from
  Association for Emergency Psychiatry
• 17 of 20 state that it is very difficult to
  determine the etiology of violent behavior
• 14 of 20 said the protocol was to physical
  restrain patients and medicate them prior to a
  medical work-up
• 15 of 20 stated that IM was the most common route
• 11 of 20 used Haldol plus lorazepam with or
  without benztropine IM.

Level III
67
ED StudiesBattaglia, J, Moss, S, Ruch, J, Et al
Haloperidol, lorazepam or both for psychotic
agitation? A multicenter, prospective,
double-blind, emergency department study. Am J
Emerg Med 1997 15335-340.

• Prospective study of 98 agitated, aggressive
  patients over 18 months
• Used rapid tranquilization method
• Given IM lorazepam (2 mg), haloperidol (5mg) or
  combination
• Undifferentiated patients
• Haloperidol had more EPS symptoms
• No difference in sedation amongst the groups
• Did not evaluate BP between groups
• Most rapid RT with combination

Level II
68
Rapid Treatment on Psych UnitAnderson, WH,
Kuehnle, JC, Catanzano, DM Rapid treatment of
acute psychosis. AM J Psychiatry 1976
1331076-1078.

• 24 patients with acute functional psychoses
  treatment with IM haloperidol over 3 hours
• Given 15-45 mg
• Almost complete remission of thought disorder in
  11 patients
• Side effects
• EPS in 8
• Blurred vision in 4
• Outpatient management may be feasible and
  preferred in the treatment of acute psychotic
  episodes

Level II
69
Treatment GuidelinesAllen, MH, Currier. GW,
Hughes, DH, Reyes, Harde, M, Docherty, JP
Treatment of behavioral emergencies. Post grad
Med 2001 S1-88.

• General Medical Etiology
• High Potency Conventional antipsychotics
• Benzodiazepine
• Combination
• Substance Intoxication
• Benzodiazepine
• Psychiatric Disturbance
• High potency conventional antipsychotics
• Benzodiazepine
• Combination

Level III
70
ProblemsSpecial populations

• Pregnant
• High-potency conventional antipsychotics lack
  known teratogenicity
• Alshuler, LL, Cohen, L , Szuba, MP, et al
  Pharmacologic management of psychiatric illness
  during pregnancy dilemmas and guidelines. Am J
  Psych 1996153592-606.
• Children
• Low dose benzodiazepine or antihistamine
• Antipsychotics risperidone or olanzapine
• Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde,
  M, Docherty, JP Treatment of behavioral
  emergencies. Post grad Med 2001 S1-88.

Level III
71
ProblemsSpecial populationsCurrier, GW
Atypical antipsychotics medications in the
psychiatric emergency services. J Clin Psych
20006121-26.

• Mental retardation
• Atypical antipsychotics
• Elderly
• Atypical antipsychotics

72
Combination TherapyPhysical Chemical Restraints

• Experts divided on whether patients who are calm
  in physical restraints need chemical restraint
• If there is continued agitation would add oral
  medication
• Relative safety of medication and physical
  restraints not studied

73
Take Home Point

• Drugs may produce psychiatric symptoms
• History is frequently unreliable
• Physical examination is an accurate tool
• Toxicology screening rarely impacts patient care

74
Take Home Point

• Medical Clearance process needs better definition
  or use of a protocol
• Short mental status exams better than current
  process
• Test patients with new onset on psychiatric
  illness
• Physical restraint is probably safe
• Chemically restrain with combination of
  haloperidol and lorazepam

75
Questions