Medical stability & Substance related emergencies M. Nadeem Mazhar MBBS, MRCPsych, FRCPC, DABPN Objectives • Review issues regarding “medical clearence” in ED • Assess common medical causes of agitation • Evaluate assessment substance related emergencies “MEDICAL CLEARANCE” Medical clearance “There is no way to rule out every possible medical illness a patient may have prior to admission to a psychiatric unit” (Zun 2005) Medical stability Making a reasonable investigation to exclude the possibility of patient having an illness that: 1. Would be better treated in a medical setting (e.g., infection requiring IV antibiotics) 2. Will cause the acute decompensation in the next few hours requiring a higher level of care (e.g., severe alcohol withdrawal) 3. Causing behavioral symptoms but should be treated by something other than psychiatric medications (e.g., delirium due to an underlying infection) 4. Worsening the psychiatric process (e.g., untreated pain that is causing the agitation) (Clinical Manual of Emergency Psychiatry) Physical examination • Evaluation of patient’s general medical status necessitates that a physical examination be performed • Physical examination may be performed by the psychiatrist, another physician, or a medically trained clinician • Particular caution in examination of patients with histories of sexual abuse- “All but limited examination of such patients should be chaperoned” (APA Practice Guidelines for Psychiatric Evaluation of Adultssecond edition, 2006) Physical examination Specific elements may include the following: • General appearance, height, weight, BMI & nutritional status • Vital signs • Head and neck, heart, lungs, abdomen, and extremities • Neurological status, including cranial nerves, motor and sensory function, gait, coordination, muscle tone, reflexes, and involuntary movements • Skin e.g., stigmata of self injury or drug use • Any body area or organ system specifically mentioned in the HPI or ROS (APA Practice Guidelines for Psychiatric Evaluation of Adults- second edition, 2006) General appearance • • • • • Cachexia- suspicion of cancer, HIV, TB, malnutrition Obvious respiratory distress Obvious physical distress or agitation Grossly dishevelled or malodorous patient Rashes- allergic or infectious diseases HEENT • Dry mucous membranes- dehydration • Pupils and eye movements- focal neurological deficits, evidence of drug intoxication/withdrawal • Scleral icterus- jaundice • Proptosis- hyperthyroidism • Bruises, lacerations- evidence of head/facial trauma • Poor dentition- nutritional status Neck • Thyromegaly- goiter, hyperthyroidism • Neck rigidity- meningitis, encaphalitis Chest • Rales- congestive heart failure • Rhonchi- pneumonia Cardiovascular • Rate, rhythm, regularity of heartbeat • Vascular disease- any absent peripheral pulses Abdomen • Hepatomegaly- undiagnosed liver disease • Acute tenderness- acute pathology that needs to be addressed in ED Extremities • Any deficits, limps or pain Neurological • • • • • Any focal deficits indicating stroke Festinating gait, rigidity- parkinsonism Tremors- EPSE, Parkinson’s disease Broad based gait- hydrocephalus, tertiary syphilis Evidence of tardive dyskinesia Diagnostic tests in Psychiatry 1. Detect or rule out presence of condition that has treatment consequences 2. Determine the relative safety and appropriate dose of potential alternative treatments 3. Provide baseline measurements before instituting treatment 4. Monitor blood levels of medication when indicated (APA Practice Guidelines for Psychiatric Evaluation of Adultssecond edition, 2006) Laboratory tests CBC: • Macrocytic anemia- vitamin B12/folate deficiency, alcohol abuse • Microcytic anemia- iron deficiency • Normocytic anemia- acute bleeding or chronic inflammatory disease • Leukocytosis- acute infection • Leukopenia- advanced HIV disease, leukemia, carbamazepine • Low platelets- Valproate, ITP Laboratory tests Electrolytes & Creatinine: • Elevated creatinine- renal failure • Hyponatremia- SSRI’s • Hypernatremia- dehydration, renal failure • Hypokalemia- risk for arrhythmia, bulimia, diuretic use • Hyperkalemia- risk for arrhythmia, renal failure • Low bicarbonate- acidosis, aspirin ingestion Laboratory tests Liver enzymes: •Elevated AST: ALT ratio- alcohol abuse •Elevated ALT & AST: liver failure due to multiple causes e.g., acetaminophen ingestion, hepatitis Laboratory tests TSH: • Elevated- hypothyroidism leading to depression, cognitive changes • Low- hyperthyroidism leading to manic like symptoms, agitation Laboratory tests Vitamin B12 & Folate: • Low B12- neurological changes, memory problems • Low folate- evidence of general malnutrition, association with depression Laboratory tests • • • • • • • Syphilis serology/HIV testing Medication levels Blood alcohol levels Fasting blood glucose or hemoglobin A1c Pregnancy test Urinalysis Urine drug screen Other investigations Chest X-ray: Considered for all homeless people, any patients with suspicion of TB, and elderly patients Head CT: In patients with altered mental status or newonset psychosis- to rule out SOL or bleeding EEG: Evidence of metabolic encephalopathy (delirium), nonconvulsive status epilepticus ECG: Medications that may influence cardiac function Lumbar puncture: Any patient with new mental status changes, fever, and/or meningeal signs- to rule out meningitis, encephalitis, bleeding, cryptococcal infection Agitation- medical causes Delirium: • Waxing and waning level of consciousness • Fluctuation in vital signs • Confusion • Can be irritable or passive and detached • More common in elderly Agitation- medical causes Hypogylcemia: • Altered mental status • Sweating • Tachycardia • Weakness Agitation- medical causes Post-ictal states: • Altered level of consciousness • Confusion • Ataxia • Todd paralysis • Neurological signs such as slurred speech • Evidence of tongue biting or incontinence Agitation- medical causes Structural brain abnormality: • Varies by lesion • Altered mental status • Headache • Meningeal signs • Focal neurological deficit or progressive neurological deterioration Agitation- medical causes Toxicologic emergency: • Varies by substance • Mental status changes • Pupillary changes • Vital sign changes • Sweating SUBSTANCE RELATED PSYCHIATRIC EMERGENCIES Initial evaluation • • • • • • Thorough history using available resources MSE Physical examination Laboratory tests Imaging studies Urine drug detection- ELISA, gas chromatography- mass spectrometry The depressed patient MSE suggestive of depression or psychomotor slowing: • • • • • • Alcohol intoxication Sedative-hypnotic toxicity Opioid toxicity OTC cough & cold medication Inhalant intoxication CNS stimulants withdrawal Alcohol intoxication • Most common cause of substance related emergencies • Studies showing up to 40% of ED patients having alcohol detected in their blood • CNS depressant effect by increasing responsivity of GABA type A receptors to GABA and inhibiting effects of glutamate at its receptors • Disinhibition at onset resulting agitation, combativeness and rarely psychosis • Dose-dependent CNS depression: Diminished coordination→ slurred speech/ataxia→ respiratory depression/coma • Legal limit: 0.05%- 0.08% (50mg/dl – 80mg/dl or 10.85 mmol/L – 17.36 mmol/L) Alcohol intoxication • Treatment of alcohol intoxication- supportive • Gastric lavage not useful due to rapid absorption of alcohol from gastrointestinal tract • Serial monitoring of toxic blood alcohol levels for expected gradual drop • Chronic alcoholics metabolize ETOH at a rate of 15-20 mg/dl per hour • In case of persistent alteration in consciousness→ exclude other causes e.g., other toxins, metabolic dysfunction or subdural hematoma Sedative-hypnotic toxicity • Can occur in acute overdoses, patients exceeding scheduled doses or with concomitant administration of other CNS depressants • Accumulation can also result in liver disease, advanced age and pharmacokinetic drug interactions • Temazepam, oxazepam, lorazepam & alprazolam metabolized primarily by conjugation- less likely to accumulate in liver impairment • Dose dependent effects on coordination, cognition and consciousness • Paradoxical agitation/excitement can also result from drug induced disinhibition Sedative-hypnotic toxicity • Vomiting, diarrhea and urinary retention can occur in BZD toxicity • Flumazenil ≤ 1mg reverses BZD effects- may precipitate seizures in dependent individuals • BZD’s rarely lethal by themselves • Synergism with other CNS depressants e.g., alcohol & opioids • Can worsen ventilation in patients with preexisting cardio-respiratory conditions e.g., OSA, COPD & CHF • High index of suspicion in patients with history of ETOH abuse • BZD misuse also likely in patients on opioids & cocaine users Opioid toxicity • Miosis + CNS & respiratory depression • Slow, shallow respiration, absent GI sounds & urinary retention • Toxicity can also result from acetaminophen or NSAIDs frequently combined with prescription opioids • Naloxone is a specific antidote→ can precipitate opioid withdrawal • Repeated doses may be required due to naloxone’s short half life OTC cold & cough medications • Frequently abused by adolescents to get “high” • May contain mixtures of various antihistamines, sympathomimetics with or without dextromethorphan • Difficult to detect in urine→ pseudoephedrine may screen positive for amphetamine Inhalant intoxication • Include a variety of hydrocarbons including toxic solvents • Initial stage of disinhibition, excitement, or a sense of drunkenness→ restlessness, ↓consciousness, ataxia, respiratory depression, coma and death with ↑inhaled concentrations • Risk of arrhythmias, possible hepatic injury and longterm effects on cognition CNS stimulant withdrawal • The cocaine “crash” • Dysphoria that may be accompanied by suicidal ideation, sleep disturbance and cravings • Increased appetite as a rebound to appetite-suppressant effects of stimulants Agitated, aggressive & psychotic patient Agitated behavior ranging from belligerence to physical aggression to full blown psychosis: • Alcohol withdrawal • Sedative-hypnotic withdrawal • Opioid withdrawal • CNS stimulant intoxication • Hallucinogen intoxication • Marijuana intoxication Alcohol withdrawal • Combativeness and aggression could be seen in both alcohol intoxication and withdrawal • BAL at which withdrawal occurs varies from patient to patient • Can begin in as little as 6 hours from the last drink • Autonomic instability: ↑BP, tachycardia & sweating • GI symptoms: Nausea, vomiting & diarrhea • CNS activation: Anxiety & tremor • Serious withdrawal: Hallucinations & seizures • Delirium tremens: After 48-72 hours, about 5% of patients in alcohol withdrawal, develop DTshallucinations (usually visual), delirium and severe autonomic instability Alcohol withdrawal & CIWA 1) Nausea and vomiting: 0-7 score 2) Tremor: 0-7 3) Paroxysmal sweats: 0-7 4) Anxiety: 0-7 5) Agitation: 0-7 6) Tactile disturbances: 0-7 7) Auditory disturbances: 0-7 8) Visual disturbances: 0-7 9) Headache: 0-7 10) Orientation: 0-4 CIWA & Medication Cumulative Score Medication Requirement 0-8 No medication 9-14 Medication optional 15-20 Medication treatment >20 Strong risk of DT 67 Maximum possible cumulative score Structured medication regimens 1) Chlordiazepoxide: • 50 mg Q6H X 4 • Followed by 25 mg Q6H X 8 2) Diazepam: • 10 mg Q6H X 4 • Followed by 5 mg Q6H X 8 3) Lorazepam: • 2 mg Q6h X 4 • Followed by 1 mg Q6H X 8 4) Carbamazepine: • 400 mg BID on day 1 • Tapering down to 200 mg as a single dose on day 5 Pharmacological treatment of alcohol withdrawal • • • • • • Benzodiazepines Anticonvulsants Beta- blocking agents Alpha-adrenergic agonists Thiamine Neuroleptic agents Sedative-hypnotic withdrawal • Occurs within the first few hours to days after discontinuation following a period of regular use • Similar to alcohol withdrawal except: extended over days to weeks (instead of hours to days) • Anxious prodrome→ tremor, tachycardia, hypertension, diaphoresis, GI upset, mydriasis, sleep disturbance & nightmares, tinnitus, ↑sensitivity to sound, light & tactile stimuli • Confusion, delirium, hyperthermia & GTCS can occur in severe withdrawal • Significant anxiety, sleep disturbance and mild autonomic symptoms may persist for many months Sedative-hypnotic withdrawal • Switch to longer acting agent & gradually taper (10%/week) • Carbamazepine 200 mg t.i.d. for 7-10 days (gabapentin and divalproex are alternatives) Opioid withdrawal • Heralded by anxiety, craving/preoccupation & vague discomfort (hyperalgesia) • Pupillary dilatation, lacrimation, rhinorrhea, diaphoresis, piloerection, arthralgia/myalgia, diarrhea, yawning & sneezing • Rarely causes change in mental status except for ↑anxiety • Onset: 6-72 hours after last use/dose • Peak: 2-4 days • Resolution: 7-10 days • Not life threatening in otherwise healthy patient • Miscarriage in pregnancy Clinical Opiate Withdrawal Scale (COWS) • • • • • • • • • • • • Resting pulse rate (0-4 score) Sweating (0-4 score) Restlessness (0-5 score) Pupil size (0-5 score) Bone or Joint aches (0-4 score) Runny nose or tearing (0-4 score) GI upset (0-5 score) Tremor (0-4 score) Yawning (0-4 score) Anxiety or irritability (0-4 score) Gooseflesh skin (0-5 score) Severity of withdrawal: 5-12= mild, 13-24= moderate, 25-36= moderately severe, >36= severe Opioid withdrawal treatment Drug Dose Withdrawal Symptoms Clonidine 0.1-0.2 mg P.r.n. b.i.d.- q.i.d. Agitation, diapohresis Dimenhydrinate 50 mg p.o. or p.r. p.r.n. nausea Ibuprofen 200-400 mg p.r.n. t.i.d. myalgia Immodium 2 mg p.r.n. max 6 tabs/day diarrhea Trazodone 50-100 mg q.h.s. p.r.n. insomnia Benzodiazepines p.r.n. anxiety CPSO MMT Guidelines-2011 CNS stimulant intoxication • Amphetamines, cocaine & MDMA • Physical signs: tachycardia, tachypnea, hypertension, mydriasis, myoclonus, hyperreflexia, tremor, vomiting, hyperthermia & possible seizures • Psychosis: paranoid delusions, tactile or visual hallucinations. Rarely FTD or bizarre delusions. Appear abruptly & resolve quickly (i.e., within days). More likely to have insight • Stimulant toxicity fatal in severe cases, often from cardiovascular or cerbrovascular causes • Treatment: minimization of stimulation, sedation with BZD, caution with neuroleptics due to the potential for lowering seizure threshold and avoiding physical restraints if possible Hallucinogen intoxication • Physical symptoms: hyperthermia & seizures • Psychological symptoms: prominent anxiety symptoms with “bad trips” including panicky feelings & fear of losing one’s mind. Psychosis is typically accompanied with relatively preserved insight • Treatment: Similar to management of stimulant intoxication Marijuana intoxication • Common presentation in chronic high-dose marijuana users is the experience of hypervigilance, depersonalization& derealization • Physical symptoms/signs: conjunctival injection, orthostatic hypotension, dry mouth & tachycardia Drug seeking patient • BZD’s for anxiety • Opioids for the treatment of pain (often out of proportion to objective findings) • Suspect drug seeking behavior: 1. When a specific medication is asked for 2. Stating that prescription was “lost” and provider not immediately available 3. Claims allergy to alternate medications 4. Threaten to be suicidal unless get prescription for specific medication SUBSTANCE RELATED PSYCHIATRIC EMERGENCIES- CASE DISCUSSION History • 35 years old with diagnoses of GAD, panic disorder with agoraphobia and antisocial personality traits presents to ER with worsening anxiety (thinks his chest and head are going to explode), diffuse muscle aches, diarrhea, nausea and sweating Medications • • • • Effexor XR 75 mg QD Epival 500 mg BID Risperidone 0.5 mg BID Clonazepam 1 mg TID + 1 mg PRN daily (concerns about abusing) Physical examination • • • • • • Temp 36.7 Pulse 101 Resp 20 BP 145/97 Oxygen sats 98% Dilated pupils Diagnosis & Treatment • Most likely substance related diagnosis? • Pharmacological treatment options? DSM-IV Sedative/Hypnotic Withdrawal Two or more of the following: • Autonomic hyperactivity (sweating or pulse rate greater than 100) • Increased hand tremor • Insomnia • Nausea or vomiting • Transient visual, tactile or auditory hallucinations or illusions • Psychomotor agitation • Anxiety • Grand mal seizures DSM-IV Opioid Withdrawal Three or more of the following: • • • • • • • • • Dysphoric moods Nausea or vomiting Muscle aches Lacrimation or rhinorrhea Pupillary dilatation, piloerection or sweating Diarrhea Yawning Fever Insomnia Reference • APA Practice Guidelines for Psychiatric Evaluation of Adults- second edition (2006). • Riba M., Ravindranath D. (2010). Clinical Manual of Emergency Psychiatry. Washington DC: American Psychiatric Publishing Inc. • Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med 2005; 28: 35-39.