Psychosis in the ED - Dr. Lara

Organic vs Non-organic etiologies

• Organic:

1. Vital sign abnormalities
2. Toxic/metabolic
3. Infectious
4. Structural
   

• High risk for organic cause:

1. increased age w no psych hx,
   
2. new/changed meds,
   
3. seizures,
   
4. HA,
   
5. immunosuppresion,
   
6. substance abuse.

• Low risk pts:
  

1. hx of psych disorder w/ similar previous episodes
2. 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:
  

1. Olanzipine- (larger dec in agitation than Haldol and less resp depression)
2. Ziprasidon- non inferior to Haldol w fewer EPS. Good tranquilization in 15min
3. 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.
  

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