Rosen & Barkin's 5-Minute Emergency Medicine Consult (770 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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ED TREATMENT/PROCEDURES
  • Verbal de-escalation:
    • Attempt to clarify and validate patient’s immediate concerns
    • Calmly explain potential need for a restraint if de-escalation is not successful
    • Offer patient choices when possible
  • Seclusion:
    • If an appropriate room is available, this may obviate the need for restraint
  • Physical restraint:
    • Follow your institutional protocol
    • Must document appropriate reason for restraint, attempts to verbally de-escalate, and plans for appropriate monitoring and reassessments
    • Whenever possible, treating physician should not be part of restraint team
    • Use leather restraints for combative patients; soft restraints for patients who are unlikely to be combative or try to elope
    • Supine position if patient needs to be examined; side position if aspiration risk is significant
    • If restraint in prone position is needed, ensure adequate airway is maintained
  • Chemical restraint:
    • Offer voluntary PO or IM sedative medication prior to initiating involuntary restraint
    • Avoid PO medications for involuntary restraint due to bite risk
    • Choice of medication should depend on underlying cause; either a benzodiazepine or a neuroleptic or both may be appropriate:
      • If agitation results from delirium or other medical condition, 1st attempt to treat the underlying cause
      • Consider benzodiazepines for hyperadrenergic (including cocaine) state or if there is a contraindication to neuroleptics
      • Consider neuroleptics for most primary medical or psychiatric causes, sedative intoxication, or primary behavioral cause
      • Often used in combination
    • Contraindications to neuroleptics:
      • Knowledge of or suspicion for Parkinson disease, dementia with Lewy bodies or frontotemporal dementia
      • Neuroleptic malignant syndrome, dystonic reaction, or catatonia
      • Prolonged QT
      • Anticholinergic overdose
    • Potential adverse effects:
      • Dystonia: Treat with IM benztropine 1 mg or IM diphenhydramine 50 mg
      • QTc prolongation and/or torsades de pointes (rare)
      • Neuroleptic malignant syndrome (rare): Stop all antipsychotics; begin intensive monitoring and supportive care
MEDICATION
ALERT
  • Patients who are elderly, have medical or neurologic illness, or have cognitive impairment are more vulnerable to adverse effects and may respond to lower doses (e.g., haloperidol 0.5 mg)
  • If 1st dose of IM haloperidol is ineffective, may be repeated after 30–60 min.
  • First line:
    • Haloperidol: 5–10 mg IV, IM, or PO
    • Lorazepam: 1–2 mg IV, IM, or PO
  • Second line:
    • Droperidol: 2.5–5 mg IV or IM; watch QTc
    • Olanzapine: 5–10 mg IM or PO; if IM, do not give with IM/IV benzodiazepines due to risk of respiratory depression
    • Risperidone: 0.5–1 mg PO
    • Ziprasidone: 10 mg IM every 2 hr, not to exceed 40 mg IM per day
FOLLOW-UP
DISPOSITION
Admission Criteria
  • Medical admission for medical conditions not temporary or reversible in the ED
  • Medical admission if further medical workup needed for which ED setting is not optimal
  • Psychiatric admission if patient has a treatable psychiatric illness appropriate for inpatient level of care
  • Involuntary admission for safety may be necessary according to criteria defined by individual state laws
Discharge Criteria
  • Underlying medical or psychiatric causes have been stabilized
  • Appropriate follow-up is in place
  • Access to weapons has been assessed
  • If intoxication played a role in presentation, sober re-evaluation should occur prior to discharge
  • Discharge to police custody may be appropriate if no psychiatric or medical issues remain
  • If patient elopes, must consider imminent danger to self or others; notify police if risk is high or if safety evaluation not complete
  • Duty to warn or protect 3rd parties from risk of harm: “Tarasoff” laws vary among states, so know yours
ADDITIONAL TREATMENT
Issues for Referral
  • Psychiatric consultation in the ED can be helpful, especially if primary mental illness suspected
  • Other consultation may be indicated based on the underlying etiology
FOLLOW-UP RECOMMENDATIONS
  • Patients with psychiatric illness should follow-up with community mental health provider
  • Patients who are using substances should be offered counseling and/or detox
PEARLS AND PITFALLS
  • Do not assume that patients with violent behavior have only psychiatric problems
  • Patients who have been restrained require appropriate monitoring, including regular nursing checks and VS, and labs/ECG if chemical restraints are used
  • “Distracting staff” is annoying and may interfere with the care of other patients, but this is not an indication for restraints
  • Document need for restraints and renewal of restraints per your hospital’s protocol
ADDITIONAL READING
  • Coburn VA, Mycyk MB. Physical and chemical restraints.
    Emerg Med Clin North Am
    . 2009;27:655–667.
  • Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: Critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department.
    Ann Emerg Med
    . 2006;47(1):79–99.
  • Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.
    West J Emerg Med
    . 2012;13(1):17–25.
  • Rossi J, Swan MC, Isaacs ED. The violent or agitated patient.
    Emerg Med Clin North Am.
    2010;28:235–256.
  • Tishler CL, Reiss NS, Dundas J. The assessment and management of the violent patient in critical hospital settings.
    Gen Hosp Psychiatry
    . 2013;35:181–185.
  • Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: Consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup.
    West J Emerg Med
    . 2012;13(1):26–34.
  • Zun LS. Pitfalls in the care of the psychiatric patient in the emergency department.
    J Emerg Med.
    2012;43(5):829–835.
See Also (Topic, Algorithm, Electronic Media Element)
  • Psychosis, Acute
  • Delirium
CODES
ICD9
  • 292.89 Other specified drug-induced mental disorders
  • 312.9 Unspecified disturbance of conduct
  • 312.30 Impulse control disorder, unspecified
ICD10
  • F19.929 Oth psychoactive substance use, unsp with intoxication, unsp
  • F63.9 Impulse disorder, unspecified
  • R45.6 Violent behavior
VISUAL LOSS
Jason Hoppe
BASICS
DESCRIPTION
  • Decrease in visual function (i.e., visual acuity, visual fields, blurry vision)
  • Visual loss has many etiologies and can be caused by multiple body systems
ETIOLOGY
  • Ophthalmologic:
    • Eyelid or tear film abnormality
    • Anterior segment (cornea, anterior chamber, iris, lens)
    • Posterior segment (vitreous, retina, optic nerve)
    • Posterior to the eye (optic nerve, chiasm, radiations)
  • Traumatic:
    • Corneal abrasion
    • Hyphema
    • Lens dislocation
    • Ruptured globe
    • Commotio retinae
    • Retinal detachment
    • Retinal/vitreous hemorrhage
    • Retrobulbar hemorrhage
    • Intraocular foreign body
  • Neurologic:
    • Cerebral (cerebrovascular accident [CVA]) or intracranial pathology (mass lesion)
    • Multiple sclerosis
    • Optic neuritis
    • Migraine
  • Cardiovascular system:
    • Embolic
    • Thrombotic
    • Ischemic
    • Hypertensive events
  • Immunologic system:
    • Uveitis
    • Giant cell arteritis
  • Infection:
    • Orbital cellulitis/abscess
    • Cavernous sinus thrombosis
    • HIV optic neuropathy or cytomegalovirus (CMV) retinitis
  • Endocrine:
    • Diabetic retinopathy
    • Thyroid disease may cause diplopia (muscle hypertrophy) or corneal erosions
  • Toxic:
    • Methanol (acute severe loss, subacute optic atrophy)
    • Licorice (transient loss, self-limited)
    • Digitalis (flashing lights, color changes)
    • Amiodarone (rare cause of optic neuropathy)

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