Psychiatric Problems in the Emergency Department ================================================ þ Axis: I - Diagnosis II - Personality Disorders III - Medical IV - Stressors V - GAF þ PEG-Intron (pegylated interferon) - effective treatment, but . . . - 75% had depression - 1/3 of all taking it still depressed 6 months later - high incidence of suicide þ Drugs and Side Effects: Drugs of Choice: - Racing thoughts: Zyprexa 5 mg QHS - Depression with anxiety, panic, hyperventilation: Paxil-CR 25 QAM: better than plain Paxil, less up and down Antipsychotics: Antidepressants: Extrapyramidal Syndromes, Dystonic Reactions, Tardive Dyskinesia: Serotonin Syndrome: þ Depression - Suicide risk higher with self-mutilation (new finding), previous attempts, men, older age groups. - Anger, remorse, or embarrassment at the time of treatment all indicate a good prognosis. The quiet patient, or the patient who refuses to talk is considered at higher risk. [Tintinalli 3rd ed. p 1077.] - Ten percent of schizophrenics will commit a successful suicide. [Tintinalli 3rd ed. p 1077. þ 302 Committments in PA - From Patty Neumeyer, MSW, Psychiatric Coordinator, MH Page #1444 - Psych nurses are paid to attend 302 hearings and are preferred as a petitioner to the emergency physician - If psych nurse refuses to petition then page Patty, #1444 - Can't redo a 302 on same information as this is double jeapordy - petitioner must either be a witness, or in the ED it's acceptable if the patient relates to the emergency physician evidence of suicidality furtherance - 302 act provides protection against civil or criminal liability for those involved in the decision-making process, whether committing or discharging, provided no gross or wilful negligence. - family members can authorize by phone to county, but have to appear to make the 302 valid. - For 302 committment, must be 18 years of age and must have, within the past 30 days, has shown likelihood that within the next 30 days will harm self or others as shown by + suicidal ideation _and_ furtherance of this (i.e., plan) + evidence of bodily injury to others + has mutilated self + debilitated to the point of possible death within 30 days - Text of Section 302: <302.TXT> þ Doctrine of Medical Restraint - Supreme Court decision 1982, Youngberg v. Romero "restaints justified to protect others or self in the judgment of the health professional." þ Problems with early medication - hard to evaluate - may miss organic problems - can't transfer - some psychotic patients will learn to use ED as medication supply þ Rapid tranquilization: - just to relieve agitation, not to abolish psychotic symptoms. - Haldol: Recommended dose: 5 mg IM, or 10-20 mg PO, remember that psychotics are good at taking PO meds. - Thorazine: 100 mg PO, 25 mg IM; no more than 1 IM dose. More sedation, but causes postural hypotension (is that bad in the Emergency Department?) - benzodiazepines: raise seizure threshold. Ativan 0.5-2 mg IM, IV, SL, PO Q1-6H - droperidol: first line in many psychiatric institutions: 2-5 mg IM or IV; no dystonic reactions - droperidol favored by the following: [Thomas H Jr, Schwartz E, Petrilli R Droperidol versus haloperidol for chemical restraint of agitated and combative patients Ann Emerg Med 1992; 21 407-13.] Abstract: [Richards JR, Derlet RW, Duncan DR Chemical restraint for the agitated patient in the emergency department: lorazepam versus droperidol J Emerg Med 1998; 16 567-73.] Abstract: [Rosen CL, Ratliff AF, Wolfe RE, et al. The efficacy of intravenous droperidol in the prehospital setting J Emerg Med 1997; 15 13-7.] Abstract: þ Panic Disorder - alprazolam (e.g., Xanax) is only approved drug; but many psychiatrists now use low doses of a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine (e.g., Prozac); usual doses of Prozac, however, can actually cause panic. [Med Ltr 1994;38(933):89] - in women, is a risk factor for MI, probably due to drugs used to treat þ Malingering þ Authority-Following Experiments