Beverly J. Fauman

Psychiatric Sequelae of Phencyclidine Abuse

Phencyclidine use has been noted to produce a psychosis of several weeks duration in a small fraction of users. Descriptions of the premorbid personalities of those who became psychotic resemble descriptions of LSD and marijuana users who experienced prolonged psychiatric difficulty. In addition, the psychosis produced can often be recognized as a hallucinogen psychosis. Certain features of the phencyclidine psychosis, namely the neurologic abnormalities, dose-related severity of symptoms, and regularity of the length of illness, are not noted with other psychedelic drugs, leading to the conclusion that PCP psychosis is a drug effect rather than a brief functional psychosis precipitated by the disintegrating PCP experience. However, the infrequent occurrence of psychosis in the (apparently) large exposed population still suggests that this is a combination of drug effect and vulnerable, pathologic personality.

The differential diagnosis of organic based psychiatric disturbance in the emergency department

The e m e r g e n c y p h y s i c i a n frequently encounters pat ients with behavioral abnormal i t ies including severe ag i ta t ion , wi thdrawal , confusion, extreme fear or anxiety, disruptire, combative, psychotic, bizarre, or inappropriate behavior. The physiclan must first establish control over the pa t ien t s behavior by reassurance, ta lk ing and, if necessary, physical restraint• He must then determine whether the patient s abnormal behavior is a resul t of a psychological (functional) process, an acute or chronic organic based disorder, or both. Many poten t ia l ly l i fethreatening organic disorders may have a behaviora l d i s t u r b a n c e as t he i r most obvious and s t r iking symptom.

Psychosis induced by phencyclidine

Phencyclidine-induced psychosis should be suspected in young adults with a history of poor social and academic performance, who present with marked anxiety, psychotic ideation, and physical signs such as nytagmus and ataxia. Phencyclidine ingestion should be suspected when the patient fails to respond to the usual reassurance and talk-down for other bad trips. A variety of drugs, as well as encephalitis or primary psychosis, can present a similar picture. Phenothiazines should be avoided in early management of any drug-induced psychosis, especially when the drug ingested is not positively identified. Phencyclidine may produce long-lasting pasychosis by unmasking psychopathology. Continued outpatient therapy including prolonged use of major tranquilizers may be necessary.

The amobarbital interview

In two apparently disoriented patients, the emergency physicians use of amobarbital quickly eliminated diagnoses of an organic etiology. Although thousands of amobarbital interviews have had no complications, the use of amobarbital should follow a thorough evaluation. The amobarbital interview is a safe and simple technique to discriminate functional from organic illness, thus avoiding unnecessary medical and surgical treatment, neglected illness, and inappropriate disposition.

A method of triage within an emergency department

University of Chicago ED has developed a Triage Scheme composed of three categories: True Emergency, Urgent and non-emergency or ambulatory clinic. Then nurses were utilized but after trying first physicians, then nurses, with indifferent results, a group of ex-military corpsmen were utilized successfully. In 18 months following the programs inception 90,000 patient visits were recorded, of which some 8,000 were admitted. Less than 1% of the patients underwent secondary triage. It is felt that one key element is insistence on taking of vital signs on all persons presenting at the emergency department.

Diabetic emergencies: hypoglycemia and ketoacidosis.

Because hypoglycemia may be rapidly fatal it must be diagnosed and treated early. Ketoacidosis may be difficult to differentiate from hypoglycemia. The diagnosis, treatment and causes of both diabetic emergencies are described. Once rehydration is instituted, further management can be directed using appropriate laboratory and bedside studies that allow stabilization with a high degree of control.