Background
Psychiatric emergencies include both primary psychiatric disorders and
manifestations of other disorders that appear to be psychiatric or involve alterations in
mental functioning. Common psychiatric emergencies include suicide risk; psychosis, if
severe or of undetermined etiology; severe depression; alterations in level of
consciousness; alcohol or drug intoxication, if severe; and alcohol or drug withdrawal.
HistoryIn documenting the history, be as specific as possible regarding details of
symptoms, onset, and duration, severity, and whether they have had a previous experience.
Specific areas to address include the presence or absence of depressive and manic
symptoms, delusions, hallucinations, suicidal or homicidal thoughts, drug abuse, and
alcohol abuse or withdrawal. Past psychiatric and family psychiatric histories should be
elicited, along with history of intent to harm oneself or other dangerous behaviors. A
complete medical history and list of medications should be documented. If available,
substantiating or conflicting data should be obtained from family members or other
acquaintances.
Physical Exam and other studies
All patients should have vital signs taken and receive a physical examination based
on review of symptoms, including a detailed mental status examination. Additional
laboratory studies vary with the clinical history. Delirium work-ups should include CBC, electrolytes, hepatic enzymes, serum alcohol
level, urine or serum drug
screens, possible
head CT, and/or EEG if trauma occurred (or history or neurological examinations reveal
abnormalities). Serum blood gas and lumbar puncture may be indicated if cardiopulmonary
status is compromised, or infection, hemorrhage, or tumor is suspected. A chest x-ray may
be indicated for patients with new onset changes in level of consciousness or psychotic
symptoms.
Differential Diagnosis
The differential diagnoses for emergent psychiatric evaluations includes mood
disorders, adjustment disorders, primary thought disorders such as schizophrenia and
reactive psychoses, anxiety disorders, substance intoxication or withdrawal, and organic
disorders which are not primarily psychiatric, but which present with symptoms commonly
associated with psychiatric disorders. The diagnosis may not be quickly evident, since
many symptoms, such as suicidal ideation and depressed mood, are common in several
different diagnostic groups. Psychiatric referral should be requested on an emergent basis
if there is evidence of suicidal ideation, acute psychosis of unknown etiology, or
agitation which does not respond to reassurance in the structured environment of the
emergency room. Consult internal medicine or neurology if there are abnormalities on the
neurologic or general physical exam, if the patient is older, or has concurrent medical
problems.
Difficult patients
Patients who are agitated, suicidal, intoxicated, or psychotic should be assigned a
1:1 watch for their safety and the safety of other medical staff. If necessary, physical
and/or chemical restraints (e.g., Haldol 5mg and Ativan 2 mg IM) may be used. If possible,
however, do not sedate the patient if a clear history has not been obtained, since altered
consciousness will impair the emergent evaluation and may mask other symptoms.
Definitive treatment of psychiatric disorders should be deferred to mental health
specialists. If the problem is primarily an adjustment disorder without significant
depressive symptoms and without suicidal ideation, the patient may be referred to a Family
Services Center, social work, or pastoral counseling. Substance abuse problems should be
referred to command alcohol counselors. Mood disorders, psychotic disorders, anxiety
disorders, suicidal patients, and severe adjustment disorders should be referred to
psychiatry or psychology for management.
Consultation
All consultation requests to psychiatry should include all pertinent
history, physical examination, and laboratory data as discussed above. This is important
because the history provided by the patient, their mental status, and laboratory findings
often change over time. Recognizing trends may be useful in establishing a diagnosis and
treatment.
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Patients who are suicidal, psychotic, severely agitated, or whom have alterations in
their level of consciousness (especially unknown etiology), should be referred emergently
to psychiatry.
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It is absolutely vital that the parent command of the patient be informed of the
situation and your plans for treatment. In many instances the command will be able to
provide valuable information which will clarify the diagnosis, and they may be able to
help ensure compliance with recommended treatment.
Reference
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Manual of Psychiatric Emergencies (The Little Brown Spiral Manual)
, edited by Steven
E. Hyman and George E. Tesar, 3rd Ed., Little Brown and Co., 1994.
Revised by CAPT William P. Nash, MC, USN, Psychiatry Specialty Leader, Naval
Medical Center San Diego (1998).