II. Epidemiology
- Adult and child psychiatry patient presentations to the emergency department are increasing
- Inadequate number of psychiatry beds and psychiatric consultants available (especially pediatric)
III. History
- Events leading up to today's evaluation?
- Recent other evaluations, hospitalizations, detox admissions or treatment programs?
- Home environment (housing, neighborhood, safety)?
- School (tardy, grades, Bullying) or work environment?
- Friends and family?
- Counseling?
- Psychiatric medications?
- Chemical use (Tobacco, Alcohol, drugs)?
- Suicidality?
- Homicidality?
- Mood (depression, anxiety)?
- Psychosis (Delusions, paranoia or Hallucinations)?
IV. Exam
- See Mental Status Exam
- See Psychosis Exam
- Full set of Vital Signs
- Neurologic Exam including gait
- Head to toe skin exam (cutting, Bruising, needle tracks)
V. Diagnostics
- See Altered Level of Consciousness
- See Unknown Ingestion
- Head imaging is not required for new onset Psychosis without focal neurologic deficit (expert opinion)
- Head imaging is based on clinical judgment
- Acute psychiatric symptoms in alert adults and children do not mandate routine lab testing
- Alert patients require a history and exam, that informs evaluation, but does not require routine labs
- Labs may be indicated to screen for medical causes based on history and exam
- Urine Drug Screen is unlikely to impact acute management (low sensitivity)
- In contrast, indiscriminate testing will result in incidental findings unrelated to the evaluation
- Negotiate with the accepting psychiatric facility if they require more than is medically indicated
- Lukens (2006) Ann Emerg Med 47(1): 79-99 [PubMed]
VI. Differential Diagnosis
VII. Findings: Red Flags for Organic Cause
- Abnormal Vital Signs
- Age <12 or over 40 years without prior psychiatric diagnosis
- Focal neurologic deficits
- Visual Hallucinations
- Psychomotor retardation
- New onset memory loss
- Abrupt onset of symptoms
- No prior psychiatric illness
- No Family History of psychiatric illness
- Substance Abuse
VIII. Evaluation: Approach
- Is this a new psychiatric illness?
- Consider organic causes and differential diagnosis
- Is this an acute decompensation of chronic psychiatric illness?
- Similar to prior exacerbations?
- Are there findings to suggest organic causes (see red flags above)
- Is there a known trigger (e.g. medication change or non-compliance, social stressors)?
IX. Evaluation: Safety
- See Suicide Risk
- No risk assessment tool can identify those safe for discharge
- Clinical judgement remains the best guide for disposition
-
Parental Consent is not required for Emergency Psychiatric Evaluation of a minor
- Primary goal is maintaining a safe environment for the child
- Physical Restraints and Sedation in Excited Delirium may be required (and do not require consent)
X. Management
- See Psychosis
- See Excited Delirium
- See Sedation in Excited Delirium
- See HEADS-ED (Mental Health Disposition Tool for Pediatric Patients)
- Approach to Children and Adolescents (per AAP)
- Patient changes into hospital gown and belongings are searched
- Interview adolescents first and then parents separately
- Reassure adolescents about confidentiality (except in Suicidality, homicidality and abuse)
- Explain the process in concrete terms, what to expect and be honest, transparent, straight-forward
- Respect their personal space
- Make children feel safe and express that their room is a safe space
- Keep school age children occupied (movie, books, toys)
- Provide food, snacks and drinks
- Attempt Verbal De-escalation if Agitation occurs (see below)
- Keep your speech calm, quiet and stay positive, friendly, and encouraging
- Avoid visual or verbal confrontation
- Limit their points of contact to 1-2 people who are caring for them
- Prepare them for multi-hour waits and keep them updated on evaluation and management
- Offer choices if available
- Emphasize their strengths
- Brave, honest to speak openly about what is bothering them
- Resilience in making it through hardships so far
- Restraints
- See Chemical Restraints
- See Physical Restraints
- Use Verbal De-escalation as a first-line strategy
- Use the lowest effective level of restraint
- Offer oral medications for anxiety, Agitation first if possible
- Paradoxical Agitation occurs with Benzodiazepines, Diphenhydramine in young children, elderly, Autism
- Consider Olanzapine (Zyprexa) if not contraindicated
XI. Disposition
- See Clinical Sobriety
- Children with expressed Suicidality or homicidality
- There are no validated criteria to assess children for subsequent Suicide Risk
- Does child understand what they did and their intent (e.g. attention-seeking)?
- Does the child have underlying condition making them unaware of their actions (e.g. Autism)?
- Do parents have insight into child's behavior and believe they can provide a safe environment?
- Discharge home precautions
- Follow-up and emergency contact information
- Follow-up appointments or scheduling phone numbers
- No access to weapons (e.g. home)
XII. References
- Lin and Wallin in Herbert (2018) EM:Rap 18(7): 9-12
- Aurora and Menchine in Herbert (2017) EM:Rap 17(10): 10-1
- Claudius, Behar and Bendaoud in Herbert (2015) EM:Rap 15(12):5
- Claudius in Herbert (2018) EM:Rap 18(6):7
- Zun, Swaminathan and Egan in Herbert (2014) EM:Rap 14(7): 11-13
- (2017) Ann Emerg Med 69(4): 480-98 +PMID: 28335913 [PubMed]
