Carolinas Emergency Medicine Residency - CMC COMPENDIUM

Carolinas Case COnference - Dr. West

3/3/2016

Psychiatric and medical co-morbidities

Schizophrenia associated with 10-25 year decrease in life expectancy
Increased risk of medical conditions with psychiatric conditions related to compliance, access to care, and substance abuse

ERIC forms

Must be mentally ill AND dangerous to self or others
All patients being admitted for psychiatric reasons need an ERIC form
Use facts, not conclusions (eg. do not state patient is suicidal, say the patient wants to kill himself by jumping into traffic).

Restraints

Often needed, but have associated risks
A new oxygen requirement suggest hypoventilation, monitor for hypercapnia
Make sure to put the order in and complete the face to face encounter (R icon in tool bar) within one hour of initiation of restraints.

Psychosis in the ED - Dr. Lara

12/12/2013

Organic vs Non-organic etiologies

Organic:

Vital sign abnormalities
Toxic/metabolic
Infectious
Structural

High risk for organic cause:

increased age w no psych hx,
new/changed meds,
seizures,
HA,
immunosuppresion,
substance abuse.

Low risk pts:

hx of psych disorder w/ similar previous episodes
no vital sign or physical exam abnormalities.

Delerium vs psychosis:

Delirium generally has fluctuating course, reduced level of consciousness, involuntary movement, associated with physical illness.

Work-up:

low risk- just H+P and physical +/- UDS and ETOH level. +/- Pregnancy Test (always a good idea)

High-risk: labs + imaging depending on presumed etiology

Therapy:

PO therapy for cooperative patients; risperdal and Ativan

IM typical antipsychotics: Haldol
IM atypical antipsychotics:

Olanzipine- (larger dec in agitation than Haldol and less resp depression)
Ziprasidon- non inferior to Haldol w fewer EPS. Good tranquilization in 15min
Combined therapy: Haldol+Ativan (good stuff). Can also use Olanzipine+midazolam.

Acep policy: agitated undifferentiated patient- benzo or typical antipsychotic
Agitated psychotic patient (likely psych)- if cooperative give po Ativan and risperdal.
If uncooperative give atypical or typical antipsychotic.