Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Look up keyword
Like this
0Activity
0 of .
Results for:
No results containing your search query
P. 1
20.Shim.10.4.12

20.Shim.10.4.12

Ratings: (0)|Views: 1|Likes:
Published by Naveen Eldose RN
Objectives Psychiatry in the Emergency Room
Discuss “medical clearance” for patients clearance” presenting with psychiatric symptoms Understand factors to help differentiate between medical and psychiatric illness Review of psychotropic medications used in the emergency setting Learn the principles of managing psychiatric emergencies

J. Jewel Shim, MD Assistant Clinical Professor of Psychiatry Director, Psychiatry Consultation and Liaison Service University of California, San Francisco

Introdu
Objectives Psychiatry in the Emergency Room
Discuss “medical clearance” for patients clearance” presenting with psychiatric symptoms Understand factors to help differentiate between medical and psychiatric illness Review of psychotropic medications used in the emergency setting Learn the principles of managing psychiatric emergencies

J. Jewel Shim, MD Assistant Clinical Professor of Psychiatry Director, Psychiatry Consultation and Liaison Service University of California, San Francisco

Introdu

More info:

Published by: Naveen Eldose RN on Jun 10, 2012
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less

10/11/2012

pdf

text

original

 
1
Psychiatry in the Emergency RoomPsychiatry in the Emergency Room
J. Jewel Shim, MDJ. Jewel Shim, MDAssistant Clinical Professor of PsychiatryAssistant Clinical Professor of PsychiatryDirector, Psychiatry Consultation and Liaison ServiceDirector, Psychiatry Consultation and Liaison ServiceUniversity of California, San FranciscoUniversity of California, San Francisco
ObjectivesObjectives
DiscussDiscussmedical clearancemedical clearancefor patientsfor patientspresenting with psychiatric symptomspresenting with psychiatric symptomsUnderstand factors to help differentiateUnderstand factors to help differentiatebetween medical and psychiatric illnessbetween medical and psychiatric illnessReview of psychotropic medications used inReview of psychotropic medications used inthe emergency settingthe emergency settingLearn the principles of managing psychiatricLearn the principles of managing psychiatricemergenciesemergencies
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 problemPerPer--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 visitsMajority 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 budgetEMTALAEMTALALess resources available to patientsLess resources available to patients2424--hour accessibilityhour accessibilityComparative ease of accessComparative ease of accessIncreased consciousness about mental healthIncreased consciousness about mental healthissuesissues
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 allpatientspatientsAssess and treat all acute medical conditionsAssess and treat all acute medical conditionsProvideProvidemedical clearancemedical clearance
What is most important for medicalWhat is most important for medicalclearance?clearance?
1.1.
ChemistryChemistry
2.2.
Urine drug screenUrine drug screen
3.3.
BUN/ BUN/ creatininecreatinine
4.4.
Physical examPhysical exam
5.5.
HistoryHistory
 
2
Medical ClearanceMedical Clearance: What is it?: What is it?
No overall consensusNo overall consensusMeans 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 treatment
11
Focused medical assessmentFocused medical assessment
22
Medical etiology excludedMedical etiology excludedAcute 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. Lukenset 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 carefulhxhx, ROS may be more, ROS may be moreeffective in identifying medical problemseffective in identifying medical problems
One study found history alone had a 94% sensitivityOne study found history alone had a 94% sensitivity
11
Low yield for most laboratory testsLow yield for most laboratory tests
UtoxUtoxBALBAL
Stratification necessaryStratification necessary
LowLowvs.vs.HighHighrisk risk 
1.1.OlshakerOlshakeret 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 Risk Low Risk 
Established psychiatricEstablished psychiatrichxhx /diagnosis /diagnosisLack of specific medical complaint/negativeLack of specific medical complaint/negativeROSROSNo physical/neurological findingsNo physical/neurological findingsStable VSStable VSNormal (age appropriate) memory andNormal (age appropriate) memory andconcentrationconcentration
Massachusetts College of Emergency Physicians, 2007Massachusetts College of Emergency Physicians, 2007
Medical Clearance:Medical Clearance:High Risk High Risk 
New symptomsNew symptomsSpecific physical/neurological complaintSpecific physical/neurological complaintLack of psychiatricLack of psychiatrichxhx /diagnosis /diagnosisOlder adultOlder adultComorbidComorbidmedical conditionsmedical conditionsPolypharmacyPolypharmacySubstance 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 stressorsPMHPMHPast psychiatric historyPast psychiatric historyMedications including recent changes, adherenceMedications including recent changes, adherenceDrug and alcohol useDrug and alcohol useFamily 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 cognitiveexam/orientationexam/orientationFocused physical and neurological examFocused physical and neurological exam
Driven by history and chief complaintDriven by history and chief complaint
Selected diagnostic work Selected diagnostic work --upup
Guided by clinical presentation andGuided by clinical presentation andphysical/neurological findingsphysical/neurological findings
Massachusetts College of Emergency Physicians, 2006Massachusetts College of Emergency Physicians, 2006
 
3
Medical MimicsMedical Mimicsof of Psychiatric DisordersPsychiatric Disorders
Many medical disorders have psychologicalMany medical disorders have psychological--behavioral manifestationsbehavioral manifestationsSometimes the first signs and symptoms areSometimes the first signs and symptoms arepsychiatricpsychiatricPatients with psychiatric histories withPatients with psychiatric histories withsignificant medicalsignificant medicalcomorbiditycomorbidity
Estimates range 7Estimates range 7--63%63%One study found 63% of One study found 63% of newnewpsychiatricpsychiatricpatients had organic etiology for presentationpatients had organic etiology for presentation
11
1.1.HennemanHennemanand Mendoza, 1994, Gregory et al., 2004and Mendoza, 1994, Gregory et al., 2004
The Divine MDThe Divine MD
DDdrug abusedrug abuseIIinfectious diseaseinfectious diseaseVVvascular disordersvascular disordersIIimmunologic/inflammatory disordersimmunologic/inflammatory disordersNNnutritional/vitaminnutritional/vitamindeficiencesdeficiencesEEendocrine disordersendocrine disordersMMmetabolic disordersmetabolic disordersDDdegenerative/ degenerative/ demyelinatingdemyelinatingdiseasesdiseasesTTtraumatraumaEEepilepsyepilepsySSstructural disordersstructural disordersTTtoxins/heavy metalstoxins/heavy metals
Brewerton, 1985Brewerton, 1985
Clues to distinguish medical fromClues to distinguish medical fromprimary psychiatric disorderprimary psychiatric disorder
New symptoms, especially in older adultNew symptoms, especially in older adultAbrupt presentationAbrupt presentationAtypical presentationAtypical presentationPresence of positive ROSPresence of positive ROSExtensive PMHExtensive PMHPolypharmacyPolypharmacyHistory of medication changeHistory of medication change
HillardHillardandandZitek Zitek , 2004, 2004
Clues to distinguish medical fromClues to distinguish medical fromprimary psychiatric disorderprimary psychiatric disorder
History of poor medication adherenceHistory of poor medication adherenceNo personal or family history of psychiatricNo personal or family history of psychiatricillnessillnessVisual, tactile, olfactory hallucinationsVisual, tactile, olfactory hallucinationsAltered/variable level of consciousnessAltered/variable level of consciousnessPresence of abnormal VS, lab data, PE/ Presence of abnormal VS, lab data, PE/ neuroneuroexamexamLack of expected response to treatmentLack of expected response to treatment
HillardHillardandandZitek Zitek , 2004, 2004
Specific Scenario: DeliriumSpecific Scenario: Delirium
Approximately 26Approximately 26--40% older ED patients with40% older ED patients withcognitive impairment or deliriumcognitive impairment or delirium
11
Only 17Only 17--33% with cognitive impairment or33% with cognitive impairment ordelirium recognized by ED physiciansdelirium recognized by ED physicians
11
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 of Of these, only 28% had documentation of mental status impairmentmental status impairment
22
1.Sanders, 2002, 2.Hustey and1.Sanders, 2002, 2.Hustey andMeldonMeldon, 2002, 2002
DeliriumDelirium
Acute alteration in level of consciousnessAcute alteration in level of consciousnessWaxes and wanesWaxes and wanesPresence of hallucinations, typically visualPresence of hallucinations, typically visualDisorientation, memory impairment, other cognitiveDisorientation, memory impairment, other cognitivedeficitsdeficitsEvidence of a medical causeEvidence of a medical causeRisk factorsRisk factors
ElderlyElderlyh/oh/odementiadementiaMultiple medical problemsMultiple medical problemsPolypharmacyPolypharmacy, medication changes, medication changesSubstance abuseSubstance abuse

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->