Kimberly Nordstrom

Medical evaluation and triage of the agitated patient: Consensus statement of the American Association for emergency psychiatry project BETA Medical Evaluation Workgroup

Numerous medical and psychiatric conditions can cause agitation; some of these causes are life threatening. It is important to be able to differentiate between medical and nonmedical causes of agitation so that patients can receive appropriate and timely treatment. This article aims to educate all clinicians in nonmedical settings, such as mental health clinics, and medical settings on the differing levels of severity in agitation, basic triage, use of de-escalation, and factors, symptoms, and signs in determining whether a medical etiology is likely. Lastly, this article focuses on the medical workup of agitation when a medical etiology is suspected or when etiology is unclear.

Managing the acutely agitated and psychotic patient.

Agitation can present as an emergency in the course of numerous psychiatric conditions including intoxication, schizophrenia, bipolar disorder, and delirium. This article reviews relevant literature regarding the definition, etiology, measurement, and management of episodic agitation and pays particular attention to intramuscular treatments. The impact of changes in methodology between the era of first- and second-generation antipsychotics, the implications of those changes for external validity of studies of second-generation studies, and the recent evolution of expert consensus are discussed.

Alternative Delivery Systems for Agents to Treat Acute Agitation: Progress to Date

Psychomotor agitation is often associated with aggression. It is important to identify agitation early and achieve results quickly in order to prevent aggressive behavior. Strategies may include verbal de-escalation techniques, reduced stimulation, medications, or a combination of approaches. Historically, pharmacological treatments for agitation have been delivered using oral and intramuscular formulations. Although the types of medication available have not changed dramatically, different formulations have been developed recently to aid in treating this difficult condition. This paper will detail some of the newer, more novel formulations used to deliver medications to treat agitation. Formulations to be described include orally disintegrating tablets, sublingual, buccal and intranasal forms, as well as an inhalation form. Each form has a unique purpose and will aid in treatment of different populations at different levels of agitation. Of note, of the medication formulations to be discussed, only inhaled loxapine is FDA approved for acute agitation in schizophrenia and bipolar disorder and no medications are approved for ‘agitation’ outside of a specific disease state. The orally disintegrating tablets of olanzapine, risperidone, and aripiprazole are swallowed and enter the circulation via the portal system. They do not have a more rapid onset of action than the standard oral tablets but are useful for patients that might otherwise divert the medication. The sublingual, buccal and intranasal formulations include asenapine and midazolam. Absorption by this route is more rapid and avoids first-pass metabolism. Finally, inhaled loxapine enters the alveoli and appears quickly in the arterial circulation. All of these novel formulations require at least some cooperation but have the potential to prevent escalation and improve the experience of patients and could be considered when negotiation is possible.

Psychiatric and Medical Management of Marijuana Intoxication in the Emergency Department

We use a case report to describe the acute psychiatric and medical management of marijuana intoxication in the emergency setting. A 34-year-old woman presented with erratic, disruptive behavior and psychotic symptoms after recreational ingestion of edible cannabis. She was also found to have mild hypokalemia and QT interval prolongation. Psychiatric management of cannabis psychosis involves symptomatic treatment and maintenance of safety during detoxification. Acute medical complications of marijuana use are primarily cardiovascular and respiratory in nature; electrolyte and electrocardiogram monitoring is indicated. This patient’s psychosis, hypokalemia and prolonged QTc interval resolved over two days with supportive treatment and minimal intervention in the emergency department. Patients with cannabis psychosis are at risk for further psychotic sequelae. Emergency providers may reduce this risk through appropriate diagnosis, acute treatment, and referral for outpatient care.

Psychiatric Emergencies in Pregnant Women

Psychiatric emergencies in pregnancy can be difficult to manage. The authors (both practicing psychiatrists and emergency clinicians) review the evaluation and treatment of common mental health diagnoses in pregnancy.

Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department

Background Suicide screening scales have been advocated for use in the ED setting. However, it is currently unknown whether patients classified as low‐risk on these scales can be safely discharged from the emergency department. This study evaluated the utility of three commonly‐used suicide screening tools in the emergency department to predict ED disposition, with special interest in discharge among low‐risk patients. Methods This prospective observational study enrolled a convenience sample of patients who answered “yes” to a triage suicidal ideation question in an urban academic emergency department. Patients were administered the weighted modified SADPERSONS Scale, Suicide Assessment Five‐step Evaluation and Triage, and Columbia‐Suicide Severity Rating Scale. Patients who subsequently received a psychiatric evaluation were included, and the utility of these screening tools to predict disposition was evaluated. Results 276 subjects completed all three suicide screening tools and were included in data analyses. Eighty‐two patients (30%) were admitted or transferred. Three patients (1%) died by suicide within one year of enrollment; one was hospitalized at the end of his or her enrollment visit, dying by suicide seven months later and the other two were discharged, dying by suicide nine and ten months later, respectively. The screening tools exhibited modest negative predictive values (range: 0.66–0.73). Conclusion Three suicide screening tools displayed modest ability to predict the disposition of patients who presented to an emergency department with suicidal ideation. This study supports the current ACEP clinical policy on psychiatric patients which states that screening tools should not be used in isolation to guide disposition decisions of suicidal patients from the ED.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations

Introduction The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs. Methods The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors. Results Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term “medical clearance,” and the need for better science in this area. Conclusion The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines

Introduction In the United States, the number of patients presenting to the emergency department (ED) for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial. Attempts have been made to establish a standard evaluation for these patients, but to date no nationally accepted standards exist. A task force of the American Association of Emergency Psychiatry, consisting of physicians from emergency medicine and psychiatry, and a psychologist was convened to form consensus recommendations on the medical evaluation of psychiatric patients presenting to EDs. Methods The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED (Part I) and then combined this with expert consensus (Part II). Results In Part I, we discuss terminological issues and existing evidence on medical exams and laboratory studies of psychiatric patients in the ED. Conclusion Emergency physicians should work cooperatively with psychiatric receiving facilities to decrease unnecessary testing while increasing the quality of medical screening exams for psychiatric patients who present to EDs.

Psychiatric Emergencies for Clinicians: The Emergency Department Management of Thyroid Storm

*University of Colorado Denver, School of Medicine, Aurora, Colorado, †UC San Diego Health System, University of California, San Diego, California, ‡Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) Lab, University of California San Diego, San Diego, California, and §Denver Health Medical Center, Department of Behavioral Health, Psychiatric Emergency Service, Denver, Colorado Reprint Address: Kimberly Nordstrom, MD, JD, Psychiatric Emergency Services, Denver Health Medical Center, 777 Bannock Street, Mailcode 0116, Denver, CO 80204

Psychiatric Emergencies for Clinicians: Emergency Department Diagnosis and Management of Steroid Psychosis

*Department of Emergency Medicine and Division of Medical Toxicology, UC San Diego Health System, University of California at San Diego, San Diego, California, †Division of Medical Toxicology, UC San Diego Health System, University of California at San Diego, San Diego, California, ‡Department of Behavioral Health, Denver Health Medical Center, Denver, Colorado, §University of Colorado School of Medicine, Aurora, Colorado, and kDepartment of Behavioral Emergencies Research, UC San Diego Health System, University of California at San Diego, San Diego, California Reprint Address: Bryan Corbett, MD, Department of Emergency Medicine and Division of Medical Toxicology, UC San Diego Health System, University of California at San Diego, 200 W. Arbor Drive, San Diego, CA 92103