Exam
Emergency Psychiatric Evaluation
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Emergency Psychiatric Evaluation
, Psychiatric Exam in the Emergency Department
See Also
Mental Status Exam
Multi-Axial Assessment
Altered Level of Consciousness
Delirium
Psychosis
Unknown Ingestion
Intoxication
Suicide Risk
Consent for Treating Minors
Violent Behavior
Excited Delirium
Epidemiology
Adult and child psychiatry patient presentations to the emergency department are increasing
Larkin (2005) Psychiatr Serv 56(6): 671-7 [PubMed]
Sills (2002) Pediatrics 110(4): e40 [PubMed]
Inadequate number of psychiatry beds and psychiatric consultants available (especially pediatric)
Baraff (2006) Ann Emerg Med 48(4): 452-8 [PubMed]
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
(
Delusion
s, paranoia or
Hallucination
s)?
Exam
See
Mental Status Exam
See
Psychosis Exam
Full set of
Vital Sign
s
Neurologic Exam
including gait
Head to toe skin exam (cutting,
Bruising
, needle tracks)
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]
Differential Diagnosis
See
Altered Mental Status Differential Diagnosis
See
Excited Delirium
See
Delirium
See
Psychosis Differential Diagnosis
See
Anxiety Secondary Cause
See
Major Depression Differential Diagnosis
See
Unknown Ingestion
Findings
Red Flags for Organic Cause
Abnormal
Vital Sign
s
Age <12 or over 40 years without prior psychiatric diagnosis
Focal neurologic deficits
Visual Hallucination
s
Psychomotor retardation
New onset memory loss
Abrupt onset of symptoms
No prior psychiatric illness
No
Family History
of psychiatric illness
Substance Abuse
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)?
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 Restraint
s and
Sedation in Excited Delirium
may be required (and do not require consent)
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 Restraint
s
See
Physical Restraint
s
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
Benzodiazepine
s,
Diphenhydramine
in young children, elderly,
Autism
Consider
Olanzapine
(
Zyprexa
) if not contraindicated
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)
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]
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