Psychiatric EmErgEnciEs 73
mEDicaL/LEgaL PitFaLLs
Involuntary administration of psychotropic medications is allowed in emergencies
that are considered life threatening. Wide variations exist in the legal definition of
“life-threatening” and in the practice of administering involuntary medication.
Timely documentation of the need for restraint and involuntary medication is
essential.
Informed consent: The most important element of informed consent is the assess-
ment of decisional capacity, for example, through the use of the Mini-Mental State Examination.
If the patient is suffering from either an organic or a functional acute change in
mental status and is a danger to self or others, then the patient should undergo emergency medical evaluation. If the patient will not voluntarily submit to this evaluation, then a request for an emergency medical evaluation from a judge, jus- tice of the peace, or police officer is obtained.
Chemical or physical restraints may be necessary in the combative patient.
Chemical restraints typically include benzodiazepines and/or antipsychotics.
Physical restraints are a last resort and are used mostly by security with close observation.
Protocols for restraints will vary by community.
Physical restraints should be used in the least restrictive manner and for the least
amount of time possible.
As required by the Joint Commission, institutions must have policies in place
that deal with the use of restraints.
A person with capacity cannot be confined or restrained against his or her will.
Doing so can lead to a legal charge of false imprisonment or battery.
Duty to warn:
Requires a clinician to warn a person who may be in danger from a combative
patient
Failure to do so may make the clinician liable for injury to the third party.
EXPErt cOnsEnsUs gUiDELinEs
treatment of Behavioral Emergencies: highlights of treatment
Support the use of oral formulations (liquid concentrate, rapidly dissolving tablets)
of atypical antipsychotics as first-line therapy for the initial management of agita- tion or aggression in the emergency setting. Provide faster times-to-peak concentra- tion. Injection peaks faster; however, oral formulations are more legally preferred and patient-centered whenever possible.
Reserve IM injections for patients unable to cooperate with oral therapy.
Other medical Emergencies in Psychiatry
DELiriUm
clinical Presentation: A condition of impaired attention, changes in behavior, and a clouded sensorium, which follows a waxing and waning course. The patient may be agi- tated, disoriented, and confused. Delirium is a disturbance of attention, not a disturbance of memory. It is acute in onset and may have concomitant neurological disturbances such as tremor, increased muscle tone, visual hallucinations, and impaired speech.
Etiology: Delirium is often caused by changes in acetylcholine balance. It can be caused by medications such as anticholinergics, narcotics, or steroids, or an underly- ing medical condition such as a urinary tract infection, liver failure, drug or alcohol abuse, or electrolyte/metabolic abnormalities. People with delirium need immediate medical attention.
incidence: Delirium occurs in 30% of all elderly medical patients. The risk of deliri- um increases for people who are demented, dehydrated, and taking drugs that affect the nervous system.
treatment: Treatment depends on the condition causing the delirium. The underly- ing medical condition should be treated first. Eliminate or change medications that can worsen confusion or that are unnecessary. Medications may be needed to control aggressive or agitated behaviors. These are usually started at very low doses and ad- justed as needed. Most often antipsychotics and sedatives are selected but should be titrated slowly in the elderly and selected to target the symptom. It should be kept in mind that benzodiazepine usage in the elderly can worsen confusion and delirium.
OthEr mEDicaL EmErgEnciEs in Psychiatry 75
Outcome: Delirium often lasts about 1 week although it may take several weeks for mental function to return to normal levels. Full recovery is common.
nEUrOLEPtic maLignant synDrOmE (nms)
clinical Presentation: NMS is a rare but life-threatening neurological emergency as- sociated with the use of antipsychotic agents and characterized by a clinical syndrome of mental status change, rigidity, fever, and dysautonomia. Mortality results from systemic complications and dysautonomia. The cardinal features include muscular ri- gidity, hyperthermia, autonomic dysfunction, and altered consciousness. Rigidity and akinesia usually develop initially or concomitantly with a temperature elevation as high as 41°C. Autonomic dysfunction includes tachycardia, labile blood pressure, dia- phoresis, dyspnea, and urinary incontinence. Creatine kinase, complete blood count, and liver function testss are usually increased. Symptoms develop over 24 to 72 hours.
Etiology: The cause of NMS is unknown but is thought to be related to central dop- amine blockade. The risk appears to be lower for the atypical antipsychotics than for the typical.
incidence: It occurs in 0.2% to 3.2% of patients. Most patients are young adults, but the disease has been described in all age groups. It can occur hours to months after initial drug exposure.
treatment: Discontinue any neuroleptic agent or precipitating drug. Maintain cardiorespiratory and euvolemic stability. Benzodiazepines can be used for agitation.
Lower fever using cooling blankets.
sErOtOnin synDrOmE
Serotonin syndrome is a potential life-threatening syndrome associated with increased serotonergic activity in the central nervous system (CNS), such as from the combination of a selective serotonin reuptake inhibitor and a monoamine oxidase inhibitor (MAOI).
It is associated with therapeutic use, drug interactions, or intentional self-poisoning.
Classically, it is a triad of mental status changes, autonomic hyperactivity, and neu- romuscular abnormalities. It is a clinical diagnosis; no laboratory test can confirm the diagnosis.
clinical Presentation: Serotonin syndrome can manifest as a wide range of clinical symptoms from mild tremor to life-threatening hyperthermia and shock. Examina- tion findings can include hyperthermia, agitation, ocular clonus, tremor, akathisia, deep tendon hyperreflexia, inducible or spontaneous clonus, muscle rigidity, dilated pupils, dry mucous membranes, increased bowel sounds, flushed skin, diaphoresis and increased heart rate, hypertension. Neuromuscular findings are typically more pronounced in the lower extremities.
Etiology: Serotonin syndrome occurs due to increased serotonin in the CNS.
Postsynaptic 5-HT1A and 5-HT2A receptors are implicated. Occurs most com- monly with the concomitant use of serotonergic drugs, with drugs that impair metabolism of serotonin, including MAOIs or with antipsychotics or other dop- amine antagonists.
treatment: Discontinue serotonergic agents. Provide supportive care such as IV fluids for hydration and benzodiazepines for agitation, myoclonus, hyperreflexia, and hyperthermia.
specific agents: Periactin (cyproheptadine) is an antihistamine with serotonergic antagonist properties. It should be considered in moderate to severe cases.
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