Em basic- psychiatric Medical Screening



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EM Basic- Psychiatric Medical Screening

(This document doesn’t reflect the views or opinions of the Department of Defense, the US Army, or the Fort Hood Post Command © 2012 EM Basic LLC, Steve Carroll DO. May freely distribute with proper attribution)


First step- “scene safety”- safety of yourself, staff, and the patient

-Patient stripped down to underwear and in a hospital gown

-Clothes and shoes stored outside the room

-Powerful deterrent to the patient suddenly leaving

-If necessary, have security/police search the patient
Know your state’s laws on involuntary holds/emergency detention
Look at chart- address abnormal vitals

-Pay special attention to fever, tachycardia, low pulse ox

-Read entire triage note for background on the patient

-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

structure? Drugs or alcohol use?

-Psych history- previous psych admission, medications


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

sensorium/mental status

-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

Chem10- electrolyte disorders (hyponatremia, renal failure, etc.)

TSH- hypothyroidism (mimics depression)

Acetiminophen level- very important - OD is asymptomatic and lethal

ETOH level- general tox workup

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

Contact- steve@embasic.org Twitter- @embasic



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