20.Shim.10.4.12

7/31/2019 20.Shim.10.4.12

1/9

Psychiatry in the Emergency RoomPsychiatry in the Emergency Room

J. Jewel Shim, MDJ. Jewel Shim, MD

Assistant Clinical Professor of PsychiatryAssistant Clinical Professor of Psychiatry

Director, Psychiatry Consultation and Liaison ServiceDirector, Psychiatry Consultation and Liaison Service

University of California, San FranciscoUniversity of California, San Francisco

ObjectivesObjectives

DiscussDiscuss medical clearancemedical clearance for patientsfor patients

presenting with psychiatric symptomspresenting with psychiatric symptomsUnderstand factors to help differentiateUnderstand factors to help differentiate

between medical and psychiatric illnessbetween medical and psychiatric illness

Review of psychotropic medications used inReview of psychotropic medications used in

the emergency settingthe emergency setting

Learn the principles of managing psychiatricLearn the principles of managing psychiatric

emergenciesemergencies

IntroductionIntroduction

A recent analysis found annual number of ED visitsA recent analysis found annual number of ED visitsincreased 20% over a 10 year period (1991increased 20% over a 10 year period (1991 --2001)2001)

About 5.5% of all ED visits during this period wereAbout 5.5% of all ED visits during this period weredue to a primarily mental health problemdue to a primarily mental health problem

PerPer--person trend for psychiatric ED visits increasedperson trend for psychiatric ED visits increasedalmost 40%almost 40%

Greatest increase seen in the overGreatest increase seen in the over--70 group:70 group:

from 46.4 to 64.1 mental health visits/1000 ED visitsfrom 46.4 to 64.1 mental health visits/1000 ED visits

Majority of visits related to mood and anxietyMajority of visits related to mood and anxietycomplaintscomplaints

Larkin et al., 2005Larkin et al., 2005

Why more ED visits?Why more ED visits?

Decrease in mental health care budgetDecrease in mental health care budget

EMTALAEMTALA

Less resources available to patientsLess resources available to patients

2424--hour accessibilityhour accessibility

Comparative ease of accessComparative ease of access

Increased consciousness about mental healthIncreased consciousness about mental health

issuesissues

Larkin et al., 2005Larkin et al., 2005

Role of the ED PhysicianRole of the ED Physician

Rapid assessment and stabilization of allRapid assessment and stabilization of all

patientspatients

Assess and treat all acute medical conditionsAssess and treat all acute medical conditions

ProvideProvide medical clearancemedical clearance

What is most important for medicalWhat is most important for medical

clearance?clearance?

1.1. ChemistryChemistry

2.2. Urine drug screenUrine drug screen3.3. BUN/BUN/creatininecreatinine

4.4. Physical examPhysical exam

5.5. HistoryHistory

7/31/2019 20.Shim.10.4.12

2/9

Medical ClearanceMedical Clearance: What is it?: What is it?

No overall consensusNo overall consensus

Means different things to different physiciansMeans different things to different physiciansShort term stability, assuming the receivingShort term stability, assuming the receivingfacility can monitor and continue treatmentfacility can monitor and continue treatment11

Focused medical assessmentFocused medical assessment22

Medical etiology excludedMedical etiology excluded

Acute illness/injury identified and treatedAcute illness/injury identified and treated

1.Massachusetts College of Emergency Physicians, 2007 2. Lukens1.Massachusetts College of Emergency Physicians, 2007 2. Lukens et al., 2006. Broderick, et al., 2001et al., 2006. Broderick, et al., 2001

Medical Clearance: What is it?Medical Clearance: What is it?

Evidence that a carefulEvidence that a careful hxhx, ROS may be more, ROS may be more

effective in identifying medical problemseffective in identifying medical problems One study found history alone had a 94% sensitivityOne study found history alone had a 94% sensitivity11

Low yield for most laboratory testsLow yield for most laboratory tests

UtoxUtox

BALBAL

Stratification necessaryStratification necessary

LowLow vs.vs. HighHigh riskrisk

1.1. OlshakerOlshaker et al., 1997, Broderick et al., 2001, Gregory et al., 2004et al., 1997, Broderick et al., 2001, Gregory et al., 2004

Medical Clearance:Medical Clearance: Low RiskLow Risk

Established psychiatricEstablished psychiatric hxhx/diagnosis/diagnosis

Lack of specific medical complaint/negativeLack of specific medical complaint/negative

ROSROS

No physical/neurological findingsNo physical/neurological findings

Stable VSStable VS

Normal (age appropriate) memory andNormal (age appropriate) memory and

concentrationconcentration

Massachusetts College of Emergency Physicians, 2007Massachusetts College of Emergency Physicians, 2007

Medical Clearance:Medical Clearance: High RiskHigh Risk

New symptomsNew symptoms

Specific physical/neurological complaintSpecific physical/neurological complaint

Lack of psychiatricLack of psychiatric hxhx/diagnosis/diagnosis

Older adultOlder adult

ComorbidComorbid medical conditionsmedical conditions

PolypharmacyPolypharmacy

Substance abuseSubstance abuse

Gregory et al., 2004Gregory et al., 2004

Medical ClearanceMedical Clearance

HistoryHistory

HPI including temporal course of symptoms,HPI including temporal course of symptoms,

recent stressorsrecent stressors

PMHPMH

Past psychiatric historyPast psychiatric history

Medications including recent changes, adherenceMedications including recent changes, adherence

Drug and alcohol useDrug and alcohol use

Family history of psychiatric disordersFamily history of psychiatric disorders

Vital signsVital signs

Massachusetts Medical College of EmergencyPhysicians, 2006Massachusetts Medical College of EmergencyPhysicians, 2006

Medical clearanceMedical clearance

Brief MSE including cognitiveBrief MSE including cognitive

exam/orientationexam/orientation

Focused physical and neurological examFocused physical and neurological exam

Driven by history and chief complaintDriven by history and chief complaint

Selected diagnostic workSelected diagnostic work--upup

Guided by clinical presentation andGuided by clinical presentation and

physical/neurological findingsphysical/neurological findings

Massachusetts College of Emergency Physicians, 2006Massachusetts College of Emergency Physicians, 2006

7/31/2019 20.Shim.10.4.12

3/9

Medical MimicsMedical Mimics ofof

Psychiatric DisordersPsychiatric Disorders

Many medical disorders have psychologicalMany medical disorders have psychological--

behavioral manifestationsbehavioral manifestations

Sometimes the first signs and symptoms areSometimes the first signs and symptoms arepsychiatricpsychiatric

Patients with psychiatric histories withPatients with psychiatric histories withsignificant medicalsignificant medical comorbiditycomorbidity Estimates range 7Estimates range 7--63%63%

One study found 63% ofOne study found 63% ofnewnew psychiatricpsychiatricpatients had organic etiology for presentationpatients had organic etiology for presentation11

1.1. HennemanHenneman and Mendoza, 1994, Gregory et al., 2004and Mendoza, 1994, Gregory et al., 2004

The Divine MDThe Divine MDDD drug abusedrug abuse

II infectious diseaseinfectious disease

VV vascular disordersvascular disordersII immunologic/inflammatory disordersimmunologic/inflammatory disorders

NN nutritional/vitaminnutritional/vitamin deficiencesdeficiences

EE endocrine disordersendocrine disorders

MM metabolic disordersmetabolic disorders

DD degenerative/degenerative/demyelinatingdemyelinating diseasesdiseases

TT traumatrauma

EE epilepsyepilepsy

SS structural disordersstructural disorders

TT toxins/heavy metalstoxins/heavy metalsBrewerton, 1985Brewerton, 1985

Clues to distinguish medical fromClues to distinguish medical from

primary psychiatric disorderprimary psychiatric disorder

New symptoms, especially in older adultNew symptoms, especially in older adult

Abrupt presentationAbrupt presentation

Atypical presentationAtypical presentation

Presence of positive ROSPresence of positive ROS

Extensive PMHExtensive PMH

PolypharmacyPolypharmacy

History of medication changeHistory of medication change

HillardHillard andand ZitekZitek, 2004, 2004

Clues to distinguish medical fromClues to distinguish medical from

primary psychiatric disorderprimary psychiatric disorder

History of poor medication adherenceHistory of poor medication adherence

No personal or family history of psychiatricNo personal or family history of psychiatricillnessillness

Visual, tactile, olfactory hallucinationsVisual, tactile, olfactory hallucinations

Altered/variable level of consciousnessAltered/variable level of consciousness

Presence of abnormal VS, lab data, PE/Presence of abnormal VS, lab data, PE/neuroneuroexamexam

Lack of expected response to treatmentLack of expected response to treatment

HillardHillard andand ZitekZitek, 2004, 2004

Specific Scenario: DeliriumSpecific Scenario: Delirium

Approximately 26Approximately 26--40% older ED patients with40% older ED patients withcognitive impairment or deliriumcognitive impairment or delirium11

Only 17Only 17--33% with cognitive impairment or33% with cognitive impairment or

delirium recognized by ED physiciansdelirium recognized by ED physicians11

One study found 26% of ED patients during aOne study found 26% of ED patients during a12 month period had mental status impairment12 month period had mental status impairment(38% of these were delirious)(38% of these were delirious)22

Of these, only 28% had documentation ofOf these, only 28% had documentation ofmental status impairmentmental status impairment22

1.Sanders, 2002, 2.Hustey and1.Sanders, 2002, 2.Hustey and MeldonMeldon, 2002, 2002

DeliriumDelirium

Acute alteration in level of consciousnessAcute alteration in level of consciousness

Waxes and wanesWaxes and wanes

Presence of hallucinations, typically visualPresence of hallucinations, typically visual

Disorientation, memory impairment, other cognitiveDisorientation, memory impairment, other cognitive

deficitsdeficitsEvidence of a medical causeEvidence of a medical cause

Risk factorsRisk factors ElderlyElderly

h/oh/o dementiadementia

Multiple medical problemsMultiple medical problems

PolypharmacyPolypharmacy, medication changes, medication changes

Substance abuseSubstance abuse

7/31/2019 20.Shim.10.4.12

4/9

Emergency PsychopharmacologyEmergency Psychopharmacology

AgitationAgitation

AssaultiveAssaultive behaviorbehavior

AnxietyAnxiety

Acute maniaAcute mania

Acute psychosisAcute psychosis

Substance intoxication/withdrawalSubstance intoxication/withdrawal

What is the most important consideration inWhat is the most important consideration in

choosing a medication for control ofchoosing a medication for control of

agitation?agitation?

1.1. RouteRoute2.2. Rapidity of onsetRapidity of onset

3.3. Duration of actionDuration of action

4.4. Medical coMedical co--morbiditiesmorbidities

5.5. Patient preferencePatient preference

Emergency Psychopharmacology:Emergency Psychopharmacology:

Important ConsiderationsImportant Considerations

RouteRoute

Rapidity of onsetRapidity of onset

Duration of actionDuration of action

Medical coMedical co--morbiditiesmorbidities

h/oh/o previous ADR/allergyprevious ADR/allergy

Need for coNeed for co--administered medicationsadministered medications

Emergency Psychopharmacology:Emergency Psychopharmacology:

Important ConsiderationsImportant Considerations

Other patient factorsOther patient factors

Age/frailtyAge/frailty

Concurrent medicationsConcurrent medications

Substance abuse historySubstance abuse history

Patient preferencePatient preference

Previous/future treatmentPrevious/future treatment

What is the preferred medication forWhat is the preferred medication for

control of acute agitation?control of acute agitation?

1.1. A benzodiazepineA benzodiazepine

2.2. Haloperidol IMHaloperidol IM

3.3. An atypical antipsychoticAn atypical antipsychotic popo4.4. Combination of antipsychotic +Combination of antipsychotic +

benzodiazepinebenzodiazepine

Expert consensus guidelines for treatmentExpert consensus guidelines for treatment

of behavioral emergenciesof behavioral emergencies

American Association for Emergency Psychiatry, 2005American Association for Emergency Psychiatry, 2005

WhenWhen dxdx uncertain, oraluncertain, oral lorazepamlorazepam oror risperidonerisperidone arearerecommendedrecommended

If IM required,If IM required, lorazepamlorazepam

IMIM ziprasidoneziprasidone,, olanzapineolanzapine, haloperidol are alternatives, haloperidol are alternatives IMIM atypicalsatypicals less desirable when medicalless desirable when medical comorbiditycomorbidity oror

intoxication presentintoxication present

WhenWhen dxdx known (mania, psychotic disorder), oralknown (mania, psychotic disorder), oralolanzapineolanzapine andand ziprasidoneziprasidone also considered highlyalso considered highlyeffective as firsteffective as first--line agentsline agents

Allen et al., 2005Allen et al., 2005

7/31/2019 20.Shim.10.4.12

5/9

Expert consensus guidelines for treatmentExpert consensus guidelines for treatment

of behavioral emergenciesof behavioral emergencies

American Association for Emergency Psychiatry, 2005American Association for Emergency Psychiatry, 2005

Oral, especially liquid formulations, preferred over IMOral, especially liquid formulations, preferred over IM

IMIM atypicalsatypicals regarded as effective alternatives to IMregarded as effective alternatives to IMhaloperidolhaloperidol

Combination treatment of an atypical + benzodiazepine wasCombination treatment of an atypical + benzodiazepine wasendorsed, except in case ofendorsed, except in case ofolanzapineolanzapine

If general medical condition present and determined to be theIf general medical condition present and determined to be thecause of the agitation, panel recommended limitingcause of the agitation, panel recommended limitingmedication, or if required, oral haloperidol ormedication, or if required, oral haloperidol or risperidonerisperidone ororIM haloperidolIM haloperidol


Clinical policy for treatment ofClinical policy for treatment of

psychiatric patients in the ED*psychiatric patients in the ED*

American College of Emergency PhysiciansAmerican College of Emergency Physicians

Clinical Policies Subcommittee, 2006Clinical Policies Subcommittee, 2006

If etiology of agitation unknown, benzodiazepines orIf etiology of agitation unknown, benzodiazepines or

haloperidol preferredhaloperidol preferred

If etiology of agitation is known, would use medicationIf etiology of agitation is known, would use medication

appropriate for agitation and initial drug therapyappropriate for agitation and initial drug therapy

DroperidolDroperidol recommended as alternative to haloperidol forrecommended as alternative to haloperidol for

quick sedationquick sedation

Oral benzodiazepine + antipsychotic preferred in agitated butOral benzodiazepine + antipsychotic preferred in agitated but

cooperative patients (cooperative patients (lorazepamlorazepam ++ risperidonerisperidone))

*medically stable patients*medically stable patientsLukens et al., 2006Lukens et al., 2006

BenzodiazepinesBenzodiazepines

MidazolamMidazolam

IM, IV, liquidIM, IV, liquid

Typical dose 1Typical dose 1--2 mg IM2 mg IM

Very quick onset, short duration of actionVery quick onset, short duration of action

IMIM within 5within 5--15 minutes15 minutes

May be a preferred agent for quick sedationMay be a preferred agent for quick sedation

NobayNobay et al., 2004, Stahl, 2005. Marco et al., 2005et al., 2004, Stahl, 2005. Marco et al., 2005

BenzodiazepinesBenzodiazepines

LorazepamLorazepam

IM, IV,IM, IV, popo (tablet, liquid)(tablet, liquid)

Typical dose 1Typical dose 1--2 mg IM/IV/2 mg IM/IV/popo

Quick onset, short to moderate duration of actionQuick onset, short to moderate duration of action

IM about 15IM about 15--20 minutes20 minutes

Good for agitation, anxiety, adjunctive use withGood for agitation, anxiety, adjunctive use with

antipsychoticantipsychotic

EtOHEtOH or benzodiazepine withdrawalor benzodiazepine withdrawal

Allen, 2000, Stahl, 2005. Marco et al., 2005Allen, 2000, Stahl, 2005. Marco et al., 2005

Other benzodiazepinesOther benzodiazepinesDiazepamDiazepam

IM, IV,IM, IV, popo (tablet, liquid)(tablet, liquid)

Long halfLong half--lifelife

ChlordiazepoxideChlordiazepoxide

IM,IM, popo

Long halfLong half

--life, lack of quick onset, IM form not well absorbedlife, lack of quick onset, IM form not well absorbed

Alternative toAlternative to lorazepamlorazepam forfor EtOHEtOH withdrawal for moderate to heavywithdrawal for moderate to heavyusers, withusers, with h/oh/o withdrawal,withdrawal, szsz, DTs, DTs

ClonazepamClonazepam

popo (tablet, quick dissolve wafer)(tablet, quick dissolve wafer)

Long halfLong half--life, lack of quick onsetlife, lack of quick onset

AlprazolamAlprazolam

popo (tablet, liquid)(tablet, liquid)

Duration of action limitedDuration of action limited

On/off or rebound effectOn/off or rebound effect

ConventionalConventional AntipsychoticsAntipsychotics::

HaloperidolHaloperidol

Most often used conventional antipsychoticMost often used conventional antipsychotic

IV, IM,IV, IM, popo (tablet, solution), depot(tablet, solution), depot

Not as sedatingNot as sedatingDosing starts 2Dosing starts 2--5 mg, 0.55 mg, 0.5--1 mg for elderly/frail1 mg for elderly/frail

patientspatients

Onset within 30Onset within 30--60 minutes60 minutes

May repeat dose after 30minMay repeat dose after 30min--1hour if no or1hour if no or

minimal effectminimal effect

7/31/2019 20.Shim.10.4.12

6/9

ConventionalConventional AntipsychoticsAntipsychotics::

HaloperidolHaloperidol

Higher incidence of EPS with IM,Higher incidence of EPS with IM, popo

DystoniasDystonias

AkathisiaAkathisia

ParkinsonismParkinsonism

Use in combination withUse in combination with anticholinergicanticholinergic

agent, benzodiazepineagent, benzodiazepine

QT interval prolongation with IV haloperidolQT interval prolongation with IV haloperidol

AtypicalAtypical AntipsychoticsAntipsychotics

Studies indicate at least equivalent efficacy toStudies indicate at least equivalent efficacy tohaloperidolhaloperidol

May be preferred because of lower incidence of EPSMay be preferred because of lower incidence of EPSThree atypicalThree atypical antipsychoticsantipsychotics available in IM formsavailable in IM formsand approved for use in agitation in schizophrenia +/and approved for use in agitation in schizophrenia +/--maniamania

ZiprasidoneZiprasidone

OlanzapineOlanzapine

AripiprazoleAripiprazole

All atypical agents approved for treatment of acuteAll atypical agents approved for treatment of acutemania and schizophreniamania and schizophrenia

AtypicalAtypical AntipsychoticsAntipsychotics:: ZiprasidoneZiprasidone

Comes inComes in popo and IMand IM

IM formulation in 10mg, 20mgIM formulation in 10mg, 20mg


May repeat dosing 10 mg q2h or 20 mg q4h, NTE 40May repeat dosing 10 mg q2h or 20 mg q4h, NTE 40

mg/24hmg/24h

Not as sedatingNot as sedating

May use with benzodiazepineMay use with benzodiazepine

QT interval prolongation?QT interval prolongation?

MendelowitzMendelowitz, 2001,, 2001, PrevalPreval et al., 2005et al., 2005

AtypicalAtypical AntipsychoticsAntipsychotics:: OlanzapineOlanzapine

ComesComes popo and IMand IM

popo tablet, dissolving wafer (tablet, dissolving wafer (ZyprexaZyprexaZydisZydis))

IM formulation comes in 5mg, 10 mgIM formulation comes in 5mg, 10 mg

Max plasma concentrations higher thanMax plasma concentrations higher thanoraloral


May repeat dose within 2h, then q4May repeat dose within 2h, then q4--6h6h prnprn,,

NTE 30 mg/24hNTE 30 mg/24hpi.lilly.com/us/zyprexapi.lilly.com/us/zyprexa--pi.pdfpi.pdf, Wright et al., 2001, Wright et al., 2001

AtypicalAtypical AntipsychoticsAntipsychotics:: OlanzapineOlanzapine

SedatingSedating

May causeMay cause orthostasisorthostasis

h/oh/o cardiovascular diseasecardiovascular disease

Patients prone to hypotensionPatients prone to hypotension

Concurrent BP lowering agentsConcurrent BP lowering agents

May need to adjust dose for special populationsMay need to adjust dose for special populations

Caution with benzodiazepinesCaution with benzodiazepines

pi.lilly.com/us/zyprexapi.lilly.com/us/zyprexa--pi.pdfpi.pdf, Wright et al., 2001, Wright et al., 2001

AtypicalAtypical AntipsychoticsAntipsychotics::

AripiprazoleAripiprazole

Comes inComes in popo (tablet, solution), dissolving ((tablet, solution), dissolving (AbilifyAbilify

DiscmeltDiscmelt) and IM) and IM

popo dosing ranges from 2.5 mgdosing ranges from 2.5 mg 15 mg15 mg

Probably not best for treating acute agitationProbably not best for treating acute agitation

IM dose 9.75 mg (range 5.25 mgIM dose 9.75 mg (range 5.25 mg 15 mg)15 mg)


May repeat q2h to max of 30 mg/24hMay repeat q2h to max of 30 mg/24h


AndrezinaAndrezina et al., 2006, Tranet al., 2006, Tran--Johnson et al., 2007Johnson et al., 2007

7/31/2019 20.Shim.10.4.12

7/9

AtypicalAtypical AntipsychoticsAntipsychotics:: RisperidoneRisperidone

Comes inComes in popo (tablet, solution), dissolving(tablet, solution), dissolving

wafer (wafer (RisperdalRisperdal MM--tabtab), depot), depotNo IM formulationNo IM formulation

Typical dosing is 1Typical dosing is 1--2mg, 0.52mg, 0.5--1mg if1mg ifelderly/frailelderly/frail


May repeat dose after 2hMay repeat dose after 2h

Currier et al., 2001, Currier et al., 2004Currier et al., 2001, Currier et al., 2004

AtypicalAtypical AntipsychoticsAntipsychotics:: RisperidoneRisperidone


May use with benzodiazepineMay use with benzodiazepine

May causeMay cause orthostasisorthostasis, tachycardia, tachycardia

h/oh/o cardiovascular diseasecardiovascular disease

Patients prone to hypotensionPatients prone to hypotension

concurrent BP lowering agentsconcurrent BP lowering agents

At doses >6 mg may see EPSAt doses >6 mg may see EPS

Currier et al., 2004 , Currier et al., 2001Currier et al., 2004 , Currier et al., 2001

AtypicalAtypical AntipsychoticsAntipsychotics::

QuetiapineQuetiapineComes inComes in popo onlyonly

Dose range 12.5 mgDose range 12.5 mg 50mg50mg

Onset within 120 minutesOnset within 120 minutes

May repeat in 2h, NTE 100 mg in first 24hMay repeat in 2h, NTE 100 mg in first 24h

SedatingSedating

May cause significantMay cause significant orthostasisorthostasis, limits use in, limits use inemergency situationsemergency situations

Alternative to benzodiazepines for patients who areAlternative to benzodiazepines for patients who areanxious and with mild agitationanxious and with mild agitation

Currier et al., 2006Currier et al., 2006

What is the primary goal of emergencyWhat is the primary goal of emergency

intervention with an agitated patient?intervention with an agitated patient?

1.1. Medical clearanceMedical clearance

2.2. Sedating themSedating them

3.3. Establishing a diagnosisEstablishing a diagnosis

4.4. Involving the patient in the treatmentInvolving the patient in the treatment

5.5. Calming them without sedationCalming them without sedation

Management ofManagement of

Psychiatric EmergenciesPsychiatric Emergencies

Recent expert consensus guidelines outlinedRecent expert consensus guidelines outlinedoverall management of behavioral emergenciesoverall management of behavioral emergencies

Included goals of emergency interventionIncluded goals of emergency intervention

Calming the patient without sedationCalming the patient without sedation Involving the patient in careInvolving the patient in care

Preserving safetyPreserving safety

Facilitate the resumption of more typical physicianFacilitate the resumption of more typical physician--patientpatientrelationshiprelationship

Obtain informed consent if possibleObtain informed consent if possible

Promote best possible longPromote best possible long--term outcometerm outcome


General Management PrinciplesGeneral Management Principles

Allen et al., 2003 surveyed consumersAllen et al., 2003 surveyed consumers preferences during apreferences during apsychiatric emergencypsychiatric emergency

Emphasized treatment with respectEmphasized treatment with respect

CollaborationCollaboration

NonpharmacologicalNonpharmacological approach preferredapproach preferred Engage patient in decision makingEngage patient in decision making e.g.,e.g., What do youWhat do you

think would be most helpful right now?think would be most helpful r ight now?

Offer patient specific optionsOffer patient specific options

Offer oral medicationsOffer oral medications

Offer choicesOffer choices

Patients prefer benzodiazepines over antipsychoticPatients prefer benzodiazepines over antipsychoticmedicationmedication


7/31/2019 20.Shim.10.4.12

8/9

General Management Principles:General Management Principles:

When to resort to IM medications?When to resort to IM medications?

Signs of escalationSigns of escalation

Increasing agitationIncreasing agitation Verbal threatsVerbal threats

Physical aggressionPhysical aggression

Unable to engage in discussion or respond toUnable to engage in discussion or respond to

limitslimits

Refusal to take oral medicationsRefusal to take oral medications

Imminent threat to safetyImminent threat to safety

AssaultiveAssaultive behaviorbehavior

Immediate action required to preserve safety ofImmediate action required to preserve safety of

patient, staff, otherspatient, staff, othersGenerally, restraints firstGenerally, restraints first

IM/IV medicationIM/IV medication

Etiology ofEtiology ofassaultiveassaultive behavior if known can guidebehavior if known can guide

choice, e.g., due to psychosis, prefer antipsychoticchoice, e.g., due to psychosis, prefer antipsychotic

medication +/medication +/-- benzodiazepinebenzodiazepine

ParanoiaParanoia

Sometimes difficult to predict escalation to agitationSometimes difficult to predict escalation to agitationoror assaultiveassaultive behaviorbehavior

Engage patient in aEngage patient in a nonconfrontationalnonconfrontational, neutral, neutralmannermanner

Avoid sustained direct eye contactAvoid sustained direct eye contact

Allow for enough space for patient, interview withAllow for enough space for patient, interview withdoor open and easy access to exitdoor open and easy access to exit

Offer food, drink, other things that might make theOffer food, drink, other things that might make thepatient more comfortable (nicotine replacement!)patient more comfortable (nicotine replacement!)

Early offer of oral medicationsEarly offer of oral medications

AnxietyAnxiety

Start withStart with nonpharmacologicalnonpharmacological approachapproach

Direct query of patientDirect query of patients immediate needss immediate needs

Offer concrete choicesOffer concrete choices

Offer oral medicationOffer oral medication

If anxiety escalates to agitation orIf anxiety escalates to agitation or assaultiveassaultive

behavior may need to administer IM/IVbehavior may need to administer IM/IV

medicationsmedications

SummarySummary

No absolute consensus on medical clearanceNo absolute consensus on medical clearance

Stratification of high and low risk of medicalStratification of high and low risk of medical

illness is necessaryillness is necessary

Medical illness can frequently present withMedical illness can frequently present with

psychiatric symptomspsychiatric symptoms

Careful review of history probably mostCareful review of history probably most

important in identifying medical etiologyimportant in identifying medical etiology

SummarySummary

Choice of medication for a behavioral emergencyChoice of medication for a behavioral emergency

includes consideration of medication characteristics,includes consideration of medication characteristics,

specific patient profile, and patient preferencespecific patient profile, and patient preference

Benzodiazepines recommended when etiology ofBenzodiazepines recommended when etiology ofagitation unknownagitation unknown

When etiology of agitation is mania or psychoticWhen etiology of agitation is mania or psychotic

disorder, oral atypicaldisorder, oral atypical antipsychoticsantipsychotics are consideredare considered

firstfirst--lineline

IMIM atypicalsatypicals are alternatives to IM haloperidolare alternatives to IM haloperidol

7/31/2019 20.Shim.10.4.12

9/9

SummarySummary

Overall management of psychiatricOverall management of psychiatric

emergencies encompasses a reasoned approachemergencies encompasses a reasoned approachthat aims to preserve safety, allow for athat aims to preserve safety, allow for a

comprehensive medical assessment, delivercomprehensive medical assessment, deliver

appropriate and compassionate treatment, andappropriate and compassionate treatment, and

include the patient in his/her careinclude the patient in his/her care

ReferencesReferences

1.1. Allen MH: Managing the agitated psychotic patient: a reappraisalAllen MH: Managing the agitated psychotic patient: a reappraisal of the evidence. Jof the evidence. J ClinClinPsychiatry 2000; 61Psychiatry 2000; 61 SupplSuppl 14:1114:11--2020

2.2. Allen MH, Carpenter D, Sheets JL,Allen MH, Carpenter D, Sheets JL, MiccioMiccio S, Ross R: What do consumers say they want andS, Ross R: What do consumers say they want andneed during a psychiatric emergency? Jneed during a psychiatric emergency? J PsychiatrPsychiatr PractPract 2003; 9(1):392003; 9(1):39--5858

5.5. Allen MH, Currier GW, Carpenter D, Ross RW, Docherty JP: The expAllen MH, Currier GW, Carpenter D, Ross RW, Docherty JP: The exp ert consensus guidelineert consensus guidelineseries. Treatment of behavioral emergencies 2005. Jseries. Treatment of behavioral emergencies 2005. J PsychiatrPsychiatr PractPract 2005; 112005; 11 SupplSuppl 1:51:5--108;108;

quiz 110quiz 110--226.6. Allen MH, Currier GW, Hughes DH, Docherty JP, Carpenter D, RossAllen MH, Currier GW, Hughes DH, Docherty JP, Carpenter D, Ross R: Treatment ofR: Treatment of

behavioral emergencies: a summary of the expert consensus guidelbehavioral emergencies: a summary of the expert consensus guidel ines. Jines. J PsychiatrPsychiatr PractPract2003; 9(1):162003; 9(1):16--3838

7.7. AndrezinaAndrezina R,R, JosiassenJosiassen RC, Marcus RN, Oren DA, Manos G, Stock E, Carson WH, IwamotoRC, Marcus RN, Oren DA, Manos G, Stock E, Carson WH, IwamotoT: IntramuscularT: Intramuscular aripiprazolearipiprazole for the treatment of acute agitation in patients withfor the treatment of acute agitation in patients withschizophrenia or schizoaffective disorder: a doubleschizophrenia or schizoaffective disorder: a double --blind, placeboblind, placebo--controlled comparison withcontrolled comparison withintramuscular haloperidol. Psychopharmacology (intramuscular haloperidol. Psychopharmacology (BerlBerl) 2006; 188(3):281) 2006; 188(3):281--9292

8.8. BreierBreier A, Meehan K,A, Meehan K, BirkettBirkett M, David S,M, David S, FerchlandFerchland I, Sutton V, Taylor CC, Palmer R,I, Sutton V, Taylor CC, Palmer R,DossenbachDossenbach M,M, KieslerKiesler G, Brook S, Wright P: A doubleG, Brook S, Wright P: A double --blind, placeboblind, placebo--controlled dosecontrolled dose--response comparison of intramuscularresponse comparison of intramuscular olanzapineolanzapine and haloperidol in the treatment of acuteand haloperidol in the treatment of acuteagitation in schizophrenia. Arch Gen Psychiatry 2002; 59(5):441agitation in schizophrenia. Arch Gen Psychiatry 2002; 59(5):441 --88

9.9. Brewerton TD. The DIVINE MD TEST. Resident and Staff PhysicianBrewerton TD. The DIVINE MD TEST. Resident and Staff Physician. 1985;31:146. 1985;31:146--8.8.

10. Broderick KB, Lerner EB, McCourt JD, Fraser E, Salerno K: Em10. Broderick KB, Lerner EB, McCourt JD, Fraser E, Salerno K: Emergency physician practicesergency physician practicesand requirements regarding the medical screening examination ofand requirements regarding the medical screening examination of psychiatric patients.psychiatric patients. AcadAcadEmergEmerg Med 2002; 9(1):88Med 2002; 9(1):88--9292

11.11. CopersinoCopersino ML,ML, SerperSerper M, Allen MH: Emergency psychiatry: rapid screening for cognitivM, Allen MH: Emergency psychiatry: rapid screening for cognitiv eeimpairment in the psychiatric emergency service: II. A flexibleimpairment in the psychiatric emergency service: II. A flexible test strategy.test strategy. PsychiatrPsychiatr ServServ2003; 54(3):3142003; 54(3):314--66


12.12. Currier GW, Chou JC,Currier GW, Chou JC, FeifelFeifel D,D, BossieBossie CA,CA, TurkozTurkoz I,I, MahmoudMahmoud RA,RA, GharabawiGharabawi GM: AcuteGM: Acutetreatment of psychotic agitation: a randomized comparison of oratreatment of psychotic agitation: a randomized comparison of ora l treatment withl treatment with risperidonerisperidoneandand lorazepamlorazepam versus intramuscular treatment with haloperidol andversus intramuscular treatment with haloperidol and lorazepamlorazepam. J. J ClinClinPsychiatry 2004; 65(3):386Psychiatry 2004; 65(3):386--9494

13.13. Currier GW,Currier GW, CitromeCitrome LL,LL, ZimbroffZimbroffDL, Oren D, Manos G,DL, Oren D, Manos G, McQuadeMcQuade R,R, PikalovPikalov AA, 3rd,AA, 3rd,Crandall DT: IntramuscularCrandall DT: Intramuscular aripiprazolearipiprazole in the control of agitation. Jin the control of agitation. J PsychiatrPsychiatr PractPract 2007;2007;13(3):15913(3):159--6969

14.14. Currier GW,Currier GW, MedoriMedori R: Orally versus intramuscularly administered antipsychotic druR: Orally versus intramuscularly administered antipsychotic drugs ings inpsychiatric emergencies. Jpsychiatric emergencies. J PsychiatrPsychiatr PractPract 2006; 12(1):302006; 12(1):30--4040

15.15. Currier GW, Simpson GM:Currier GW, Simpson GM: RisperidoneRisperidone liquid concentrate and oralliquid concentrate and oral lorazepamlorazepam versusversusintramuscular haloperidol and intramuscularintramuscular haloperidol and intramuscular lorazepamlorazepam for treatment of psychotic agitation. Jfor treatment of psychotic agitation. JClinClin Psychiatry 2001; 62(3):153Psychiatry 2001; 62(3):153--77

16.16. Currier GW, Trenton AJ, Walsh PG, vanCurrier GW, Trenton AJ, Walsh PG, van WijngaardenWijngaarden E: A pilot, openE: A pilot, open--label safety study oflabel safety study ofquetiapinequetiapine for treatment of moderate psychotic agitation in the emergencyfor treatment of moderate psychotic agitation in the emergency setting. Jsetting. J PsychiatrPsychiatrPractPract 2006; 12(4):2232006; 12(4):223--88

17.17. Daniel DG,Daniel DG, PotkinPotkin SG, Reeves KR, Swift RH,SG, Reeves KR, Swift RH, HarriganHarrigan EP: Intramuscular (IM)EP: Intramuscular (IM) ziprasidoneziprasidone20 mg is effective in reducing acute agitation associated with p20 mg is effective in reducing acute agitation associated with psychosis: a doublesychosis: a double--blind,blind,randomized trial. Psychopharmacology (randomized trial. Psychopharmacology (BerlBerl) 2001; 155(2):128) 2001; 155(2):128--3434

18.18. Gregory RJ,Gregory RJ, NihalaniNihalani ND, Rodriguez E: Medical screening in the emergency departmentND, Rodriguez E: Medical screening in the emergency department forforpsychiatric admissions: a procedural analysis. Gen Hosp Psychiatpsychiatric admissions: a procedural analysis. Gen Hosp Psychiat ry 2004; 26(5):405ry 2004; 26(5):405--1010

19.19. HennemanHenneman PL, Mendoza RJ.PL, Mendoza RJ. PropsectivePropsective evaluation of emergency department medicalevaluation of emergency department medicalclearance. Annclearance. Ann EmergEmerg Med. 1994; 24:672Med. 1994; 24:672--7.7.

20.20. HillardHillard R,R, ZitekZitekB. Emergency medicine approach to psychiatric illness. In EmerB. Emergency medicine approach to psychiatric illness. In Emergencygency

Psychiatry. New York: McGrawPsychiatry. New York: McGraw--Hill. 2004:3Hill. 2004:3--14.14.


21.21. HusteyHustey FM,FM, MeldonMeldon SW: The prevalence and documentation of impaired mental statusSW: The prevalence and documentation of impaired mental status ininelderly emergency department patients. Annelderly emergency department patients. Ann EmergEmerg Med 2002; 39(3):248Med 2002; 39(3):248--5353

22.22. KohenKohen I,I, PrevalPreval H, Southard R, Francis A: Naturalistic study of intramuscularH, Southard R, Francis A: Naturalistic study of intramuscular ziprasidoneziprasidoneversus conventional agents in agitated elderly patients: retrospversus conventional agents in agitated elderly patients: retrosp ective findings from aective findings from apsychiatric emergency service. Am Jpsychiatric emergency service. Am J GeriatrGeriatr PharmacotherPharmacother 2005; 3(4):2402005; 3(4):240--55

23.23. KornKorn CS, Currier GW, Henderson SO: "Medical clearance" of psychiatriCS, Currier GW, Henderson SO: "Medical clearance" of psychiatric patients withoutc patients withoutmedical complaints in the Emergency Department. Jmedical complaints in the Emergency Department. J EmergEmerg Med 2000; 18(2):173Med 2000; 18(2):173--66

24.24. Larkin GL,Larkin GL, ClaassenClaassen CA,CA, EmondEmond JA, Pelletier AJ,JA, Pelletier AJ, CamargoCamargo CA: Trends in U.S. emergencyCA: Trends in U.S. emergencydepartment visits for mental health conditions, 1992 to 2001.department visits for mental health conditions, 1992 to 2001. PsychiatrPsychiatr ServServ 2005; 56(6):2005; 56(6):

671671--77

25.25. Lukens TW, Wolf SJ,Lukens TW, Wolf SJ, EdlowEdlow JA,JA, ShahabuddinShahabuddin S, Allen MH, Currier GW,S, Allen MH, Currier GW, JagodaJagoda AS:AS:Clinical policy: critical issues in the diagnosis and managementClinical policy: critical issues in the diagnosis and management of the adult psychiatricof the adult psychiatricpatient in the emergency department. Annpatient in the emergency department. Ann EmergEmerg Med 2006; 47(1):79Med 2006; 47(1):79--9999

26.26. Marco CA, Vaughan J: Emergency management of agitation in schizoMarco CA, Vaughan J: Emergency management of agitation in schizophrenia. Am Jphrenia. Am J EmergEmergMed 2005; 23(6):767Med 2005; 23(6):767--7676

27.27. MarderMarder SR: A review of agitation in mental illness: treatment guidelinSR: A review of agitation in mental illness: treatment guidelines and currentes and currenttherapies. Jtherapies. J ClinClin Psychiatry 2006; 67Psychiatry 2006; 67 SupplSuppl 10:1310:13--2121

28.28. Massachusetts College of Emergency Physicians Consensus statemenMassachusetts College of Emergency Physicians Consensus statemen t on medical clearance.t on medical clearance.http://http://www.macep.org/practice_information/medical_clearance.htmwww.macep.org/practice_information/medical_clearance.htm

29.29. MendelowitzMendelowitz AJ: The utility of intramuscularAJ: The utility of intramuscular ziprasidoneziprasidone in the management of acutein the management of acutepsychotic agitation. Annpsychotic agitation. Ann ClinClin Psychiatry 2004; 16(3):145Psychiatry 2004; 16(3):145--5454


30.30. NobayNobay F, Simon BC,F, Simon BC, LevittLevitt MA, Dresden GM: A prospective, doubleMA, Dresden GM: A prospective, double--blind, randomized trialblind, randomized trialofofmidazolammidazolam versus haloperidol versusversus haloperidol versus lorazepamlorazepam in the chemical restraint of violent andin the chemical restraint of violent andseverely agitated patients.severely agitated patients. AcadAcad EmergEmerg Med 2004; 11(7):744Med 2004; 11(7):744--99

31.31. OlshakerOlshaker JS, Browne B,JS, Browne B, JerrardJerrard DA, Prendergast H, Stair TO. M edicalDA, Prendergast H, Stair TO. Medi cal cleranceclerance andandscreening of psychiatric patients in the emergency department.screening of psychiatric patients in the emergency department. AcadAcad EmergEmerg Med. 1997; 4:Med. 1997; 4:124124--8.8.

32.32. PrevalPreval H, Klotz SG, Southard R, Francis A: RapidH, Klotz SG, Southard R, Francis A: Rapid--acting IMacting IM ziprasidoneziprasidone in a psychiatricin a psychiatricemergency service: a naturalistic study. Gen Hosp Psychiatry 200emergency service: a naturalistic study. Gen Hosp Psychiatry 200 5; 27(2):1405; 27(2):140--44

33.33. Sanders AB: Missed delirium in older emergency department patienSanders AB: Missed delirium in older emergency department patien ts: a qualityts: a quality--ofof--carecareproblem. Annproblem. Ann EmergEmerg Med 2002; 39(3):338Med 2002; 39(3):338--4141

34.34. Stahl, SM. Essential Psychopharmacology: TheStahl, SM. Essential Psychopharmacology: The PrescriberPrescriberss Guide. Cambridge: CambridgeGuide. Cambridge: CambridgeUniversity Press; 2005.University Press; 2005.

35.35. TranTran--Johnson TK, Sack DA, Marcus RN,Johnson TK, Sack DA, Marcus RN, AubyAuby P,P, McQuadeMcQuade RD, Oren DA: Efficacy andRD, Oren DA: Efficacy andsafety of intramuscularsafety of intramuscular aripiprazolearipiprazole in patients with acute agitation: a randomized, doublein patients with acute agitation: a randomized, double--blind, placeboblind, placebo--controlled trial. Jcontrolled trial. J ClinClin Psychiatry 2007; 68(1):111Psychiatry 2007; 68(1):111--99

36.36. Wright P,Wright P, BirkettBirkett M, David SR, Meehan K,M, David SR, Meehan K, FerchlandFerchland I,I, AlakaAlaka KJ, Saunders JC, Krueger J,KJ, Saunders JC, Krueger J,Bradley P, San L, Bernardo M,Bradley P, San L, Bernardo M, ReinsteinReinstein M,M, BreierBreier A: DoubleA: Double--blind, placeboblind, placebo--controlledcontrolledcomparison of intramuscularcomparison of intramuscular olanzapineolanzapine and intramuscular haloperidol in the treatment ofand intramuscular haloperidol in the treatment ofacute agitation in schizophrenia. Am J Psychiatry 2001; 158(7):1acute agitation in schizophrenia. Am J Psychiatry 2001; 158(7):1149149--5151

37.37. ZimbroffZimbroffDL, Allen MH,DL, Allen MH, BattagliaBattaglia J,J, CitromeCitrome L,L, FishkindFishkind A, Francis A, Herr DL, Hughes D,A, Francis A, Herr DL, Hughes D,Martel M,Martel M, PrevalPreval H, Ross R: Best clinical practice withH, Ross R: Best clinical practice with ziprasidoneziprasidone IM: update after 2 yearsIM: update after 2 yearsof experience. CNSof experience. CNS SpectrSpectr 2005; 10(9):12005; 10(9):1--1515

38.38. ZyprexaZyprexa. Prescribing information.. Prescribing information. http://pi.lilly.com/us/zyprexahttp://pi.lilly.com/us/zyprexa --pi.pdfpi.pdf. Revised November. Revised November30, 2006.30, 2006.

20.Shim.10.4.12

Documents

Transcript of 20.Shim.10.4.12