-Is this suicidal ideation (SI) or more of the patient acting
bizarrely? (more altered mental status than SI)
Introduce yourself to the patient, sit down and listen -For safety, stay in between the patient and the door
-Don’t get trapped in the room
-Ask the patient why they are in the ED
-Be prepared to listen but be direct if the patient doesn’t talk
-If they don’t volunteer it- ask the patient “do you want to hurt
yourself or anyone else”
-If the patient has SI, ask them directly what their plan is
PEARL: You aren’t going to make a patient suicidal or give them ideas just by asking- you need to ask these questions directly to get the whole story
Pay attention to the patient’s body language
-Are they being evasive?
-Are they hyper and on edge?
-Are they somnolent and depressed?
-Are they blowing off your concerns about SI?
If the patient has a plan to hurt themselves- how serious are they about carrying it out?
-Method doesn’t matter- what matters is how much the patient believes it will hurt them
-Example- 10 motrin won’t kill an adult but if the patient believes that it will, take it seriously
Ask about social and psychiatric history
-Social history- who does the patient live with? Support
Get full medical history- meds, allergies, PMH, PSH
Do a good review of symptoms- focus on neuro and endocrine
Do a good head to toe exam- focus on the neuro exam and mental status
-Some suggest doing a mini-mental status on every patient
-Probably not necessary but make sure the patient has a clear
-Pay attention to any confusion or fluctuating mental status
Labs- very low yield on young healthy patients but required by psych facilities/floors prior to admission- trying to catch undiagnosed medical conditions contributing/causing psych condition
General lab workup with possible explanations CBC- anemia
Salicylate leve- same (but this is a recognizable toxidrome)
UA/Urine Drug Screen- UTI, drugs of abuse
Urine HCG- females= pregnant until proven otherwise
EKG- arrhythmias or prolonged arrhythmias (contraindication to some psych meds, can help you diagnose TCA overdose)
LFTs- optional- screen for liver disease?
Catching the red flags
-Most important part of this workup is to find those patients who have a medical condition causing their psychiatric illness
-Be careful in the young and the old and patients who all of the sudden have psychiatric problems without a previous history
Example- young patient starts suddenly acting bizarrely- could be herpes meningitis, older patient with SI with no stressors- could be a head bleed
PEARL- Red Flags- Sudden onset of symptoms, age greater than 40, visual or tactile hallucinations, fluctuating level of consciousness Patients with red flags should get a non-contrast head CT and a lumbar puncture looking for intracranial masses/bleeding or meningitis and any other indicated testing Bottom line- you have to pretend that you will be the last medical doctor that will see the patient- may be a long time before they see a doctor other than a psychiatrist
Disposition Acting bizarrely with a known history of psychiatric illness- if history/exam, workup, and sensorium is normal may be able to discharge if the patient doesn’t want to stay (you have a right to act bizarrely on the streets as long as you aren’t hurting anyone or breaking any laws)- get social services help if you can
SI/HI-Should be evaluated by a psychiatrist in the ED
Psychiatrist agrees with admission- admit the patient to the psych floor/facility- may be a long wait- get the patient something to eat, make them comfortable, give benzos PRN for agitation
Psychiatrist disagrees with admission- make sure the patient hasn’t changed their story when they talked to the psychiatrist, make sure the psychiatrist has the whole picture/story
Suicide Risk assessment- at community EDs without ready access to psychiatry, may have to make SI low risk vs. high risk decision- go to blog.ercast.org/suicide for podcasts and other information on this topic