Psychiatric Emergencies



Psychiatric Emergencies


Sanjay Mehta



Introduction



  • Children often present to the emergency department in crisis



    • Suicidality, behavioral crisis/aggression, acute psychosis, or anxiety


  • Crisis: acute emotional upset (normal response to abnormal life events) arising from situational, developmental, or sociocultural sources resulting in temporary inability to cope through usual problem-solving devices


  • Psychiatric emergencies: acute behavioral disturbances related to severe mental or emotional instability or dysfunction that requires medical intervention (e.g., medication or admission)


  • Rule out organic etiologies for change in behavior before psychiatric consultation


  • Determine if agitated and withdrawn children are psychotic


  • Need to conduct a risk assessment to determine risk of self-harm or harm to others


Clinical Assessment of Psychiatric Emergencies



  • Identifying complaint



    • Source and reason for referral, who patient lives with, and source of information


  • Chief complaint and history of present illness



    • Time of onset, duration, predisposers, precipitators, perpetuators, and severity


  • Mood symptoms



    • Depression: irritable or depressed mood, loss of interest/pleasure (anhedonia), reactivity, feeling sad, change in appetite or weight, sleep disturbance, loss of energy and
      fatigue, social isolation and withdrawal, poor concentration and indecisiveness, worthlessness, and feelings of guilt, low self-esteem, or feeling hopeless


    • Mania: agitation, mood elevation, pressured speech or grandiosity


  • Anxiety symptoms



    • Isolated or generalized worries, age-inappropriate phobias, panic, obsessions, compulsions, dissociations, flashbacks, and avoidance


  • Psychotic symptoms



    • Circumstantiality, loosening of associations, delusions, auditory or visual hallucinations, communicating telepathically, thought broadcasting or insertion, catatonia or changed affect (e.g., flat, inappropriate, or incongruent)


  • Psychiatric history



    • Psychiatric hospitalizations, outpatient treatment, psychiatric diagnoses, psychiatric medications, involvement with child protection services, counselors


  • Medical and developmental history



    • Pregnancy, birth, delivery, milestones, medical illnesses, hospitalizations, or diagnoses, past and current medications


  • Personal history



    • Previous level of adjustment, social (family and peer relations), academic performance, areas of interest and special competences, behavioral functioning, abuse (sexual or physical), substance abuse, aggression, violence, body image, eating problems, sexual preference or orientation


  • Family history



    • Psychiatric disorders and medications, relationships, suicides in extended family, substance abuse


Suicidality and Homicidality Assessment



  • Past or present suicidal/homicidal behaviors



    • Suicidal or homicidal thoughts, thoughts about death or dying, or hurting or killing, and for how long, or previous
      attempts or rehearsals (method, severity, impulsivity, suicidal or homicidal note or notification of others)


    • Red flags: plan and means available (pills, knives, poison, and especially firearms)


  • Risk factors for suicidality (often attempting to escape dysphoria)



    • Disciplinary or amorous crises, circumstances leading to shame (e.g., bullying, coming out), males, family history, “contagion effect,” mood or conduct disorders, impulsiveness, and certain personality factors, substance use, isolation, or alienation


  • Self-harm or mutilation (often attempting to seek euphoria)



    • Can have significant tissue damage, usually fixed and rhythmic, often superficial from carving, cutting, burning, etc.


  • Threat of self-harm supercedes right of confidentiality



    • Guardians have right to be informed of risk to their wards








Table 67.1 Features of Agitated or Withdrawn Child




































THE AGITATED CHILD

THE WITHDRAWN CHILD


•

Anxious, upset, unresponsive

•

Unresponsive, quiet, non-rapport


•

Pacing, loud, abusive, disoriented

•

Clinging, whining, crying


•

Tantrums, crying, violent

•

Sullen, apathetic


•

Distraught, sullen, angry

•

Different from shyness


•

Improve in ED with structure


○

Temperamental quality within range of normal behavior

○

Sense of forthcoming help


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Jun 22, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Psychiatric Emergencies

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