ACİL PSİKİYATRİ

Tüm acil psikiyatrik hastalıklarının1. substance-related disorders - 30%2. mood disorders -23%3. anxiety disorders -21%4. psychosis -10%5. suicide attempts -7%

• Psikiyatrik acillerde*suisidal ve ya homosidal davranışlar*major depresyon veya ankisyete*psikoz*mania*ani bilişsel ve ya davranışsal deyişiklikler

• Acil psikiyatrik değerlendirme ve sorgulama*mevcut hastalığının ve semptomlarının tarihi*Suisidalite ve homosidalitenin

değerlendirildmesi 1.plan? 2.düşünce? 3.daha önceden girişim var mı?

*şu anki sorunlarıyla ilişkili tıbbi sorunları*keçmiş psikiyatrik öykü *Alkol madde kullanımı*Aile öyküsü*

BAĞIMLILIĞIN DEĞERLENDİRİLMESİkullanım yaşımiktar ve sıklığıkullanım yolu (oral nazal iv)son defa kullandığı tarihsosial durumu (iş durumu okul aksaması

yasal sorumluluk)hastanın kesilme ve ya yoksunluk

sendomundakı motivasyonu!!hastanın kesilme ve ya yoksunluk

sendormunda tıbbi durumuyla ilgili bilgisi

Often, presentations to the PES are complicated, and patients may be unable, or unwilling, to provide an accurate history. For this reason an important feature of the evaluation is the collection of history from multiple sources (including family, friends, treaters, police, or emergency personnel who transported the patient). When several informants can be interviewed, data can be corroborated from the various sources, which can help the psychiatrist make informed disposition decisions.

• For any patient treated at an ED with an altered mental status (be it a change in cognition, emotional state, or behavior), it is crucial to rule out an underlying medical condition that causes or contributes to the problem

• A change in mental state may indicate a primary psychiatric condition, a primary medical condition with psychiatric symptoms, delirium (an acute and reversible condition secondary to a medical illness), or dementia (a chronic condition associated with long-term, irreversible brain pathology)

• Diagnosis using Diagnostic and Statistical Manual of Mental• Disorders, 4th edition (DSM-IV) criteria21 can be difficult in• the PES because patients are seen at a single point in time,• often in the worst crisis of their lives. Although patients• will not necessarily fit the criteria exactly, a search for the• most common disorders (e.g., mood disorders, psychosis,• anxiety disorders, substance abuse, and a change in mental• status caused by a medical etiology [such as delirium])• will facilitate assessment. The following pages will outline• some of the most common psychiatric presentations and• patient characteristics in the ED.

• The Depressed PatientDepression is a common reason for seeking treatment at aPES. The severity of the depression may vary from mild toextremely severe; it may occur with or without psychosisor suicidal thinking. Anhedonia and other neurovegetativesymptoms of depression are common complaints. Anxietyor anger attacks are often co-morbid with depression, anda history of mania must be assessed in every depressedpatient to screen for bipolar disorder. Other medical conditions,especially hypothyroidism, must be considered. Theseverity of symptoms and the ability to participate in workand other routines may contribute to a diagnosis; however,the assessment of safety is essential in treatment planning.

• The Anxious PatientAlthough symptoms of anxiety may reflect a primary anxietydisorder, anxiety often heralds other disorders. Patientswith psychosis may first describe anxiety about peoplewho might try to harm them; patients with depressionmay have anxiety about financial or relationship difficulties.Psychomotor agitation, fidgeting, and pacing co-occurwith anxiety but may also correlate with psychosis, alcoholwithdrawal, or cocaine intoxication. Medical problems(e.g., hyperthyroidism, delirium) and medication sideeffects (e.g., akathisia) may also be confused with anxiety.Chest pain and shortness of breath resulting from a panicattack are also common presentations to the ED that willrequire thorough medical evaluation in concert with apsychiatric evaluation.

The Psychotic PatientPatients with psychosis suffer from disorganized thinking,hallucinations, delusions, or other forms of disorderedthought (e.g., ideas of reference, thought broadcasting, orthought insertion). Patients with psychosis vary greatly inthe severity of their symptoms; they may be affected by paranoiathat has undermined their work or relationships or sufferfrom loose associations, delusions, or aggressive behavior.Because some patients have lost touch with reality and maybe at risk for agitation or dangerousness, awareness for thesafety of staff and other patients must be maintained. Amongpatients with new-onset psychosis, severe anxiety is common,and it may be difficult to differentiate from paranoia.It is also important to rule out medical causes for symptoms,particularly among patients who lack a history of psychosisand whose age falls outside the usual range for theonset of psychosis (late teens to mid-20s). Auditory hallucinationsare more common with psychiatric disorders,whereas visual hallucinations are more common in medicaldisorders, delirium, and substance abuse. Seizure disorders,delirium, metabolic changes, infections, ingestion,and withdrawal from alcohol or benzodiazepines shouldbe considered in the differential for new-onset psychosis.Among the elderly with new-onset hallucinations, deliriumand dementia should be strongly considered

The Manic PatientManic patients can often be disruptive and provocative,with pressured speech, grandiosity, irritability, and flight ofideas. Such patients may be dressed or behave in an odd orseductive manner and may have impulsively traveled longDistancesIt is important to assess for medical causes ofmania, as well as for acute intoxication with cocaine orphencyclidine (PCP). Steroids can also contribute to manicsymptoms, as can antidepressant medications.

• The Patient with Intoxication or Withdrawal• Patients with substance intoxication or withdrawal often• come to the attention of emergency personnel because of• acute medical symptoms (e.g., unconsciousness, difficulty• breathing, confusion). However, they may also come to the• ED requesting referral for detoxification services or other• substance abuse treatment• Alcohol• Alcohol intoxication can cause disorientation, ataxia, and• slurring of speech; when high blood alcohol levels (BALs)• are present, respiratory depression, coma, and death may• leg cramps (limit to once per day on account of cardiovascular• or renal toxicity)

The symptoms of cocaine intoxicationinclude euphoria and grandiosity, irritability or agitation,lack of sleep, dilated pupils, and psychomotor restlessness(e.g., pacing, hand wringing, foot tapping, or choreiformlikemovements). Patients may experience elevated bloodpressure and temperature, tachycardia, palpitations, chestpain, and shortness of breath. Some patients experiencehallucinations, paranoia, or agitation; antipsychotic medicationsare a useful treatment.Serum toxicology screens for cocaine, if available, mayconfirm very recent use of cocaine (within hours), whereasurine toxicology may confirm use up to 24 hours previously.Although there is no clearly described withdrawal syndromefor cocaine, patients often experience a very strongurge to sleep once cocaine has left their system. They alsodescribe feeling weak and tired, with cravings for days toweeks after use has ended.

• Crystal Methamphetamine• Intoxication with crystal methamphetamine and other• amphetamines may be recognized by mood lability or

irritability,• psychomotor agitation, confusion, and sweating.• More severe cases may include paranoia, hallucinations,• seizures, and fever. Treatment is supportive. Psychotic• symptoms can be treated with antipsychotics.23

Withdrawal• from amphetamines leads to agitation, irritability, sleep• disturbance, psychomotor agitation, and depressed mood.

• Marijuana• Marijuana is a common drug of abuse among patients• treated at the PES. Symptoms of intoxication include• relaxed or elevated mood, alteration in the perception

of• time, tachycardia, and conjunctival injection.23

Patients• may report paranoia or hallucinations, although in

these• cases it is important to assess for other drugs of abuse

and• for underlying psychiatric disorders as well.

• The Patient with a Change in Mental Status• When treating a patient who displays a significant change• in mental state, the emergency psychiatrist must identify• the underlying etiology. In general, changes in mental• state represent delirium, dementia, or psychiatric conditions.• Because psychiatric conditions are often a diagnosis• of exclusion in the acute presentation, delirium and• dementia must be ruled out. The Folstein Mini-Mental• State Examination24 can be useful to screen for cognitive• changes. Dementia, a chronic and progressive condition• characterized by memory and other cognitive impairments,• is discussed elsewhere in this textbook (see Chapter 11).• Delirium, as defined by DSM-IV,21 is a fluctuating state• of consciousness and cognition that is caused by a variety• of medical conditions. Delirium, also known as acute• confusional state or encephalopathy, typically has an acute• onset (over hours to days), has a fluctuating course, and is• reversible.

• Psychomotor agitation is• also common, though psychomotor retardation is possible. Symptoms typically associated with psychiatric

diagnoses• (e.g., auditory and visual hallucinations, acute changes in• mood, psychotic or disorganized thoughts) may also be• seen in delirious states. Although certain underlying• medical conditions are commonly associated with certain• symptoms (e.g., anxiety or agitation with pheochromocytoma,• mania with use of corticosteroids, and depression• with interferon treatment), the underlying medical condition• cannot be diagnosed by its presentation alone; all possible• medical conditions must be considered• Delirium may represent a serious or life- threatening• condition. These conditions include Wernicke’s encephalopathy,• hypoxia, hypoglycemia, hypertensive encephalopathy,• intracerebral hemorrhage, meningitis/• encephalitis, poisoning (exogenous or iatrogenic), and• seizures. Their assessment and treatment are outlined• in Table 39–4. Other, less urgent conditions (including• subdural hematoma, septicemia, subacute bacterial• endocarditis, hepatic or renal failure, thyrotoxicosis or• myxedema, delirium tremens, anticholinergic psychosis,• and complex partial status epilepticus) may require• acute interventions.25

• MANAGEMENT OF ACUTE SYMPTOMS• The primary goal in the PES is to manage acute crises.• The intervention chosen will depend on the patient’s• needs, the severity of illness, and the time and resources• available. For some patients the intervention consists of• the opportunity to speak to an understanding clinician,• who can form an alliance, demonstrate empathy, and provide• reassurance. Other patients require IM medication or• restraint for agitation. Between those extremes are various• therapeutic interventions designed to decrease the acuity• of the patient’s situation, provide education about mental• illness and treatment, and help the patient and family• members make informed decisions about treatment

• Intervention with Medication• Never underestimate the power of medication in a psychiatric• emergency. For some patients, particularly those who• are psychotic or acutely agitated, administering medication• may be the primary intervention. Medication can decrease• anxiety and paranoia, improve disorganization, and help a• manic patient to sleep. Benzodiazepines decrease symptoms• of alcohol withdrawal. Some patients who are initially• overwhelmed are able to participate in the interview and• psychological intervention only after medication has been• administered. Medication should be considered early and• often in the process of an evaluation. If the patient uses a• medication at home on an as-needed basis for similar symptoms• or has tried a medication before, the same medication• can be offered to minimize potential side effects of new• medications. If the patient has not tried medications, consideration• of the symptoms, differential diagnosis, intended• means of administration of the medication, and potential• side effects will help narrow down the options.27,28• Potential medication regimens in the PES include benzodiazepines• (particularly lorazepam [0.5 to 1 mg] PO or• IM; a benzodiazepine should always be the first choice if• alcohol withdrawal is suspected); atypical neuroleptics (e.g.,• risperidone [0.5 to 1 mg] in oral tablet, liquid, or rapidly• dissolving form or olanzapine [2.5 to 5 mg] in oral tablet• or rapidly dissolving form); and high-potency neuroleptics• (e.g., haloperidol) combined with a benzodiazepine and an• anticholinergic agent (diphenhydramine or benztropine)• for more severe agitation. A commonly used combination• that can be administered PO or IM is haloperidol 5 mg and• lorazepam 2 mg, plus diphenhydramine 25 to 50 mg (for• prophylaxis of dystonia). Newer parenteral formulations of• atypical neuroleptics for the management of acute agitation• are also available; options include olanzapine 10 mg• IM, ziprasidone 10 to 20 mg IM, and aripiprazole 9.75 mg IM.• Table 39–5 lists a range of medications that are used for• adult patients in the PES.

• Treatment After the Acute Crisis• The emergency psychiatrist must have a thorough• knowledge of the local mental health resources. Inpatient• units, crisis stabilization units, residential treatment

services,• partial hospitalization programs, detoxification• units, and outpatient programs serve as alternative levels• of care after the PES evaluation. Admission criteria vary,• and many programs depend on prior approval by insurance• companies. The acuity of the patient’s symptoms, the• insurance coverage, and the psychosocial support system• must all be weighed to determine the appropriate level of• care. Decisions made with the patient, the family, and other• treaters should be coordinated.

• The Personality-Disordered Patient• Patients with borderline or antisocial personalities usually• require a significant amount of time from PES staff• to coordinate their care. Such patients may request special• services or favors that are outside of the normal routine• of the unit. They may file complaints or even threaten to• harm or kill themselves or others if the clinician is unwilling• to provide the treatment that the patient prefers. These• threats often are statements of desperation, though each• statement must be evaluated with the patient’s history and• current situation in mind.• Problems often occur because of splits between staff• members who disagree about how the patient should be• managed. The most important aspect of the treatment of• these patients is for the PES team to provide clear boundaries• regarding the scope of care available, the role of• individual staff members, and the goal of the emergency• intervention. Outside contacts who know the patient may• be able to provide insight for the purposes of the safety• assessment

• The Grieving Patient• Management of acute grief (e.g., after a traumatic

event• or a death within the ED, the loss of a relationship,

or• the anniversary of a loss) is a common reason for

referral• to the PES. Grief is the normal response to loss and

can• manifest in many ways, including feelings of shock,

sadness,• anxiety, anger, and guilt.30

• Victims of Domestic Violence and Trauma• Domestic violence (i.e., an individual’s use of force to inflict• emotional or physical injury on another person with whom• the individual has a relationship) affects spouses, partners,• children, grandparents, and siblings of all races and• genders. Between 2 and 4 million women are abused• each year in the United States, and domestic violence• has become the leading cause of injury among women• between 15 and 44 years of age.31 Men can also be victims• of domestic violence.• Patients in the PES should be asked whether they have• been a victim of violence or trauma, whether this contributes• to their presenting symptoms, and whether they are• safe in their current living environment. Symptoms of• posttraumatic stress disorder should be screened for and• included in treatment planning. Patients need not be asked• to describe explicit details about past traumas. Instead, the• patient can be helped to understand that the process of• working through trauma should occur with a therapist who• can provide long-term support, and then the clinician can• provide an appropriate referral.

• The Homeless Patient• It is estimated that approximately 20%6 to 30%32 of the• patients who are treated at PESs are homeless,6 and this• characteristic adds complexity to the psychiatric evaluation.• When a patient has insomnia or the fear of being• harmed by others, it may be difficult to determine whether• the symptoms are due to a psychiatric disturbance or the• inherent risks of homelessness. Homeless patients are at• greater risk for substance abuse, tuberculosis, skin conditions,• and other serious chronic medical conditions (e.g.,• diabetes, acquired immunodeficiency syndrome [AIDS],• and cancer); it is especially important to provide good medical• screening during the assessment. The clinician must• also account for the patient’s housing situation and access• to meals and medical care in the course of disposition planning.• A treatment plan adapted to these realities is much• more likely to succeed33; however, despite careful disposition• planning, homeless patients are more likely than other• patients to have repeat visits to the PES

• ROLE OF THE PSYCHIATRIST• IN DISASTER PREPARATION• In the face of recent catastrophic events such as terrorist• attacks and large-scale natural disasters, efforts have been• undertaken to prepare medical teams to manage disasters.• The role of psychiatry in this response is often overlooked• until the actual event occurs. In the midst of a disaster• response, the psychiatrist’s ability to tolerate extreme affect• becomes immediately useful. The psychiatrist can offer aid• in at least four different arenas: organizational aid and planning• for disaster response; treatment of psychological reactions• to stress (using pharmacologic, psychotherapeutic,• and interpersonal interventions), acutely and over the long• term; provision of support to family members and friends• of victims of the disaster; and support of medical staff who• participate in disaster response (including emergency personnel,• hospital staff, administrative staff, and other support• personnel).43,44• Emergency psychiatrists are particularly well adapted• to assist with disaster response. They are familiar with the• medical and psychological effects of trauma, adept at working• with grieving family members, and familiar with the• resources in the community that can assist with long-term• treatment. Disaster psychiatry is a growing field, and emergency• psychiatrists will likely play an important role in the• future of disaster-response planning.