Emergency Psychiatric Evaluation

Aka: Emergency Psychiatric Evaluation, Psychiatric Exam in the Emergency Department, Psychiatric Emergency

II. Definitions

  1. Psychiatric Emergency
    1. Acute, impending risk of harm to self or others (e.g. Suicidality, aggression)

III. Epidemiology

  1. Adult and child psychiatry patient presentations to the emergency department are increasing
    1. Larkin (2005) Psychiatr Serv 56(6): 671-7 [PubMed]
    2. Sills (2002) Pediatrics 110(4): e40 [PubMed]
  2. Inadequate number of psychiatry beds and psychiatric consultants available (especially pediatric)
    1. Baraff (2006) Ann Emerg Med 48(4): 452-8 [PubMed]

IV. History

  1. See Adolescent History (HEADSS Screening)
  2. Events leading up to today's evaluation?
  3. Recent changes in behavior and mood (depression, anxiety)??
  4. Recent other evaluations, hospitalizations, detox admissions or treatment programs?
  5. Home environment (housing, neighborhood, safety)?
  6. School (tardy, grades, Bullying) or work environment?
  7. Developmental Delay or special needs (e.g. Autism)?
  8. Family Relationships?
  9. Friend Relationships?
  10. Sexual Activity?
  11. Counseling?
  12. Psychiatric medications?
  13. Chemical use (Tobacco, Alcohol, drugs)?
  14. Suicidality (ideation, planning, preparation and prior attempts)?
  15. Homicidality?
  16. Psychosis (Delusions, paranoia or Hallucinations)?
  17. Physical Abuse or Sexual Abuse?
    1. See Intimate Partner Violence
    2. See Physical Abuse in Children
    3. See Sexual Abuse in Children
    4. See Sexual Assault

V. Exam

  1. Full set of Vital Signs
  2. See Mental Status Exam
  3. See Psychosis Exam
  4. Neurologic Exam including gait
  5. Head to toe skin exam (cutting, Bruising, needle tracks)

VI. Diagnostics

  1. See Altered Level of Consciousness
  2. See Unknown Ingestion
  3. Head imaging is not required for new onset Psychosis without focal neurologic deficit (expert opinion)
    1. Head imaging is based on clinical judgment
  4. Acute psychiatric symptoms in alert adults and children do not mandate routine lab testing
    1. Alert patients require a history and exam, that informs evaluation, but does not require routine labs
    2. Labs may be indicated to screen for medical causes based on history and exam
    3. Urine Drug Screen is unlikely to impact acute management (low sensitivity)
    4. In contrast, indiscriminate testing will result in incidental findings unrelated to the evaluation
    5. Negotiate with the accepting psychiatric facility if they require more than is medically indicated
    6. Lukens (2006) Ann Emerg Med 47(1): 79-99 [PubMed]

VII. Differential Diagnosis

  1. See Altered Mental Status Differential Diagnosis
  2. See Excited Delirium
  3. See Delirium
  4. See Psychosis Differential Diagnosis
  5. See Anxiety Secondary Cause
  6. See Major Depression Differential Diagnosis
  7. See Unknown Ingestion

VIII. Findings: Red Flags for Organic Cause

  1. Abnormal Vital Signs
  2. Age <12 or over 40 years without prior psychiatric diagnosis
  3. Focal neurologic deficits
  4. Visual Hallucinations
  5. Psychomotor retardation
  6. New onset memory loss
  7. Abrupt onset of symptoms
  8. No prior psychiatric illness
  9. No Family History of psychiatric illness
  10. Substance Abuse

IX. Evaluation: Approach

  1. Is this a new psychiatric illness or an organic condition?
    1. Consider organic causes and differential diagnosis (see above)
  2. Is this an acute decompensation of chronic psychiatric illness?
    1. Similar to prior exacerbations?
    2. Are there findings to suggest organic causes (see red flags above)
    3. Is there a known trigger (e.g. medication change or non-compliance, social stressors)?

X. Evaluation: Safety

  1. See Suicide Risk
  2. See HEADS-ED (Mental Health Disposition Tool for Pediatric Patients)
  3. No risk assessment tool can identify those safe for discharge
    1. Clinical judgement remains the best guide for disposition
  4. Parental Consent is not required for Emergency Psychiatric Evaluation of a minor
    1. See Consent for Treating Minors
    2. Be aware of state laws
    3. Primary goal is maintaining a safe environment for the child
    4. Physical Restraints and Sedation in Excited Delirium may be required (and do not require consent)

XI. Management

  1. See Altered Level of Consciousness
  2. See Psychosis
  3. See Excited Delirium
  4. See Sedation in Excited Delirium
  5. Approach to all patients
    1. Patient changes into hospital gown and belongings are searched for dangerous weapons
    2. Patient should be in a safe mental health room
      1. Remove self-harm risk items (e.g. electrical cords, cutlery)
      2. Quiet environment sheltered from the noise and commotion of the rest of the emergency department
      3. High risk patients should have sitter and/or video surveillance
    3. Adapt evaluation as needed to cultural and developmental needs
    4. Explain the process in concrete terms, what to expect and be honest, transparent, straight-forward
    5. Attempt to develop rapport with patient
    6. Respect their personal space
    7. Provide food, snacks and drinks
    8. Attempt Verbal De-escalation if Agitation occurs (see below)
      1. Keep your speech calm, quiet and stay positive, friendly, and encouraging
      2. Avoid visual or verbal confrontation
    9. Prepare them for multi-hour waits and keep them updated on evaluation and management
    10. Offer choices if available
    11. Emphasize their strengths
      1. Brave, honest to speak openly about what is bothering them
      2. Resilience in making it through hardships so far
  6. Approach to Children and Adolescents (per AAP, includes approach to all patients above)
    1. See Consent for Treating Minors
    2. Interview adolescents first and then parents separately
    3. Reassure adolescents about confidentiality (except in Suicidality, homicidality and abuse)
    4. Make children feel safe and express that their room is a safe space
    5. Parents may have calming effect for children (although in other cases they may trigger anxiety or adverse behavior)
    6. Keep school age children occupied (movie, books, toys)
    7. Limit their points of contact to 1-2 people who are caring for them
    8. Adapt evaluation to developmental level of child
      1. Does child understand the concept and finality of Suicide?
      2. Is Suicidality their expression of sadness and hopelessness, not a wish to die?
  7. Restraints
    1. See Chemical Restraints
    2. See Physical Restraints
    3. Use Verbal De-escalation as a first-line strategy
    4. Use the lowest effective level of restraint
    5. Offer oral medications for anxiety, Agitation first if possible
    6. Paradoxical Agitation occurs with Benzodiazepines, Diphenhydramine in young children, elderly, Autism
      1. Consider Olanzapine (Zyprexa) if not contraindicated

XII. Disposition

  1. Assess safety for discharge home versus inpatient psychiatry (often in combination with telepsychology assessment)
    1. See Clinical Sobriety
    2. See Suicidality (includes Suicide Risk Factors)
    3. Homicidality
    4. Acute Delirium
  2. Children with expressed Suicidality or homicidality
    1. See HEADS-ED (Mental Health Disposition Tool for Pediatric Patients)
    2. There are no validated criteria to assess children for subsequent Suicide Risk
    3. Does child understand what they did and their intent (e.g. attention-seeking)?
    4. Does the child have underlying condition making them unaware of their actions (e.g. Autism)?
    5. Do parents have insight into child's behavior and believe they can provide a safe environment?
    6. Has there been a prior Suicide attempt (highest risk for teenage Suicide)?
  3. Discharge home precautions
    1. Follow-up and emergency contact information
    2. Follow-up appointments or scheduling phone numbers
    3. No access to weapons (e.g. home)
  4. Outpatient Resources
    1. Primary care follopw-up
    2. Community mental health resources
    3. Community social services
    4. Suicidality Safety Plan

XIII. References

  1. Lin and Wallin in Herbert (2018) EM:Rap 18(7): 9-12
  2. Aurora and Menchine in Herbert (2017) EM:Rap 17(10): 10-1
  3. Claudius, Behar and Bendaoud in Herbert (2015) EM:Rap 15(12):5
  4. Claudius in Herbert (2018) EM:Rap 18(6):7
  5. Grover and Onyinyechi (2021) Crit Dec Emerg Med 35(3): 3-7
  6. Zun, Swaminathan and Egan in Herbert (2014) EM:Rap 14(7): 11-13
  7. (2017) Ann Emerg Med 69(4): 480-98 +PMID: 28335913 [PubMed]

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