II. 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]

III. History

  1. Events leading up to today's evaluation?
  2. Recent other evaluations, hospitalizations, detox admissions or treatment programs?
  3. Home environment (housing, neighborhood, safety)?
  4. School (tardy, grades, Bullying) or work environment?
  5. Friends and family?
  6. Counseling?
  7. Psychiatric medications?
  8. Chemical use (Tobacco, Alcohol, drugs)?
  9. Suicidality?
  10. Homicidality?
  11. Mood (depression, anxiety)?
  12. Psychosis (Delusions, paranoia or Hallucinations)?

IV. Exam

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

V. 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. 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

VIII. Evaluation: Approach

  1. Is this a new psychiatric illness?
    1. Consider organic causes and differential diagnosis
  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)?

IX. Evaluation: Safety

  1. See Suicide Risk
  2. No risk assessment tool can identify those safe for discharge
    1. Clinical judgement remains the best guide for disposition
  3. Parental Consent is not required for Emergency Psychiatric Evaluation of a minor
    1. Primary goal is maintaining a safe environment for the child
    2. Physical Restraints and Sedation in Excited Delirium may be required (and do not require consent)

X. Management

  1. See Psychosis
  2. See Excited Delirium
  3. See Sedation in Excited Delirium
  4. See HEADS-ED (Mental Health Disposition Tool for Pediatric Patients)
  5. Approach to Children and Adolescents (per AAP)
    1. Patient changes into hospital gown and belongings are searched
    2. Interview adolescents first and then parents separately
    3. Reassure adolescents about confidentiality (except in Suicidality, homicidality and abuse)
    4. Explain the process in concrete terms, what to expect and be honest, transparent, straight-forward
    5. Respect their personal space
    6. Make children feel safe and express that their room is a safe space
    7. Keep school age children occupied (movie, books, toys)
    8. Provide food, snacks and drinks
    9. 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
    10. Limit their points of contact to 1-2 people who are caring for them
    11. Prepare them for multi-hour waits and keep them updated on evaluation and management
    12. Offer choices if available
    13. Emphasize their strengths
      1. Brave, honest to speak openly about what is bothering them
      2. Resilience in making it through hardships so far
  6. 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

XI. Disposition

  1. See Clinical Sobriety
  2. Children with expressed Suicidality or homicidality
    1. There are no validated criteria to assess children for subsequent Suicide Risk
    2. Does child understand what they did and their intent (e.g. attention-seeking)?
    3. Does the child have underlying condition making them unaware of their actions (e.g. Autism)?
    4. Do parents have insight into child's behavior and believe they can provide a safe environment?
  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)

XII. 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. Zun, Swaminathan and Egan in Herbert (2014) EM:Rap 14(7): 11-13
  6. (2017) Ann Emerg Med 69(4): 480-98 +PMID: 28335913 [PubMed]

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