Mental Health Book



Emergency Psychiatric Evaluation

Aka: Emergency Psychiatric Evaluation, Psychiatric Exam in the Emergency Department
  1. See Also
    1. Mental Status Exam
    2. Multi-Axial Assessment
    3. Altered Level of Consciousness
    4. Delirium
    5. Psychosis
    6. Unknown Ingestion
    7. Intoxication
    8. Suicide Risk
    9. Consent for Treating Minors
    10. Violent Behavior
    11. Excited Delirium
  2. 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]
  3. Exam
    1. See Mental Status Exam
    2. See Psychosis Exam
  4. 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 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. In contrast, indiscriminate testing will result in incidental findings unrelated to the evaluation
  5. 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)
  6. Management
    1. See Psychosis
    2. See Excited Delirium
    3. See Sedation in Excited Delirium
  7. Disposition
    1. See Clinical Sobriety
    2. Children with expressed Suicidality or homicidality
      1. Does child understand what they did and their intent (e.g. attention-seaking)?
      2. Does the child have underlying condition making them unaware of their actions (e.g. Autism)?
      3. Do parents have insight into child's behavior and believe they can provide a safe environment?
  8. References
    1. Aurora and Menchine in Herbert (2017) EM:Rap 17(10): 10-1
    2. Claudius, Behar and Bendaoud in Herbert (2015) EM:Rap 15(12):5
    3. Zun, Swaminathan and Egan in Herbert (2014) EM:Rap 14(7): 11-13
    4. (2017) Ann Emerg Med 69(4): 480-98 +PMID: 28335913 [PubMed]

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