Evidence Based Evaluation and Treatment of Psychiatric Patient in the Emergency Setting

Transcription

1 Evidece Based Evaluatio ad Treatmet of Psychiatric Patiet i the Emergecy Settig Leslie S Zu, MD, MBA, FAAEM Presidet, America Associatio for Emergecy Psychiatry Chairma ad Professor Departmet of Emergecy Medicie ad Psychiatry RFUMS/Chicago Medical School Chicago, Illiois

2 Disclosure PI for two research grats sposored by Teva Pharmaceuticals to Siai Health System EMF Grat for agitatio research

3 Learig Objectives To uderstad the medical clearace process To use protocols i the evaluatio of the psychiatric patiets To uderstad the role of verbal deescalatio i the treatmet of psychiatric patiets To improve the choice of treatmet modalities for psychiatric patiets i the emergecy settig

4 Case #1 64 year old female is brought to the hospital for maic behavior. Patiet has multiple medical problems but o prior psychiatric history. What further iformatio is eeded? What to look for i the physical exam? What testig is idicated?

5 Case #2 36 year old male with schizophreia was brought i by the family because he stopped takig his medicatio ad is gettig violet at home. What further iformatio is eeded? What to look for i the physical exam? What testig is idicated?

6 Medical Clearace Purpose Primary Purpose - To determie whether a medical illess is causig or exacerbatig the psychiatric coditio. Secodary Purpose - To idetify medical or surgical coditios icidetal to the psychiatric problem that may eed treatmet.

7 Primary Purpose Etiology Schizophreia Bipolsr Illess Depressio Drug ad alcohol itoxicatio or withdrawal Medical Hypoglycemia Hyperthyroidism Delirium Head Trauma Temporal Lobe Epilepsy Psychiatric Psychiatric Medical Delirium Demetia Hyperthyroidism Head Trauma Temporal Lobe Epilepsy Drug itoxicatio/ withdrawal

8 Mortality Rate of Delirium Barro, EA ad Holmes, J: Delirium withi the emergecy care settig, occurrece ad detectio: a systematic review. Emerg Med J 2013;30: ED icidece 7-20% Frequetly missed 24% maximum detectio rate Due to lack of screeig High rate of mortality 36% vs. 10% High rate of morbidity High rate of icotiece, decubitus, malutritio

9 Cocurret Medical Problems Retrospective review of 300 patiets 178 had medical problems ad 122 did ot Most commo hypertesio, asthma ad diabetes

10 Cocurret Substace Use Safer, D: Substace abuse by youg adult chroic patiets Hosp Commu Psych 1987;38: % curret substace users 29% history of substace use 27% had little or o substace use history

11 Primary Purpose - Differetiate Medical from Psychiatric Etiology History Physical exam Metal status examiatio Cogitive assessmet Laboratory testig?

12 What part of the evaluatio is useful? Olshaker, JS, Browe, B, Jerrard, DA, Predergast, H, Stair, TO: Medical clearace ad screeig of psychiatric patiets i the emergecy departmet. Acad Emerg Med 1997;4: Retrospective, observatio study of psychiatric patiets over 2 moth period 352 patiets with 19% havig medical problems Sesitivity History 94% Physical exam 51% Vital sigs 17% Laboratory testig 20%

13 History Is the patiet reliable? Olshaker, JS, Browe, B, Jerrard, DA, Predergast, H, Stair, TO: Medical clearace ad screeig of psychiatric patiets i the emergecy departmet. Acad Emerg Med 1997;4: Patiets asked about drug ad alcohol use Patiets had alcohol ad toxicological screeig Reliability of patiets self-reported history Sesitivity Specificity Drugs 92% 91% ETOH 96% 87%

14 Evaluatio Cocers Who Does the Psychiatric Evaluatio ED MD I-house psychiatry ED metal health worker Telepsychiatry Commuity metal health Outside cotracted metal health worker The bottom lie is ED physicia s or psychiatrist s resposibility to esure correct dispositio

15 Formal Metal Status Examiatio Elemets routiely assessed while iterviewig pt Appearace, behavior ad attitude Mood ad affect Not routiely assessed while iterviewig pt Disorders of thought-suicidal & homicidal ideatio,?admit Isight ad judgmet-kowledge about illess Disorder of perceptio-halluciatios & delusios Sesorium ad itelligece-cogitive impairmet,?delirium

16 Clock Drawig Test Preferred as a screeig test Self-admiistered ad takes a short time to complete. The Clock test is scored o a six poit scale from o errors to o reasoable represetatio of a clock. Patiets with a score of oe or two are cosidered cosider without impairmet ad those with three or great have cogitive impairmet.

17 Who Needs Testig ad What Tests? What labs are doe? CBC, lytes, UDS, ETOH, UCG Evidece that routie labs rarely chage cliical maagemet Drug scree, alcohol level Oe idicatio - Altered metal status without etiology Whe is more advaced testig idicated? EEG, EKG, CT Sca Head, Chest radiograph Which patiets? All comers Chroically metal illess with same presetatio New oset

18 Are Routie Labs Idicated? Lukes, TW et al: Cliical Policy: Critical issues i the diagosis ad maagemet of adult psychiatric patiet i the emergecy departmet. A Emerg Med 2006;46: APA Practice Guidelies o Psychiatric Evaluatio of Adults ACEP Guidelies Routie testig laboratory testig of all patiets is of very low yield ad eed ot be performed. I adult ED patiets with primary psychiatric complaits, diagostic evaluatio should be cliically directed by the history ad physical examiatio. APA Guidelies Psychiatrist may eed to request or iitiate further geeral medical evaluatio to address diagostic cocers that emerge from the psychiatric evaluatio. Psychiatrists ad emergecy physicias sometimes have differet viewpoits o the utility of laboratory screeig.

19 Are drug ad alcohol testig idicated? Routie urie toxicologic screes for drugs i alert, awake, cooperative patiets do ot affect ED maagemet ad eed ot be performed (ACEP Guidelie) The patiet s cogitive abilities, rather tha a specific blood alcohol level, should be the basis o whe the cliicias begi the psychiatric assessmet. (ACEP Guidelie) Itoxicatio is a cliical diagosis; ot a lab diagosis Level of cosciousess Cogitive fuctio Neurologic fuctio Coordiatio Gait Nystagmus

20 Which patiets? Psych history vs. ew oset Heema, PL, Medoza, R, Lewis, RJ: Prospective evaluatio of emergecy departmet medical clearace. A Emerg Med 1994;24: cosecutive patiets aged with ew psychiatric symptoms. Patiets with fever received CT ad LP 63 of 100 had orgaic etiology for their symptoms History i 27 PE i 6 CBC i 5 SMA-7 i 10 CPK i 6 ETOH ad drug scree i 28 CT sca i 8 LP i 3. Patiets eed extesive laboratory ad radiographic evaluatios icludig CT ad LP.

21 Is There a Differece Betwee Routie ad Cliically Idicated Testig? Studies demostrated that most people will have oe or more tests out of the ormal rage i routie testig Studies have revealed that routie testig i psych patiets do ot chage maagemet Cliically idicated testig may be of value for such as patiets with a physical complait, blood levels of medicatios or medical illesses

22 Whe is Testig Idicated? Red flags of medical etiology Age >45 years old Exposure to toxis or drugs Substace itoxicatio or withdrawal No prior psychiatric/medical history Abormal vital sigs Cogitive deficits Focal eurologic fidigs Slurred speech Seizures New oset of psychiatric symptoms Accommodatig psychiatric facility

23 Protocol for the Emergecy Medicie Evaluatio of Psychiatric Patiets: Zu, LS, Leike, JB, Scotlad, NL et. al: A tool for the emergecy medicie evaluatio of psychiatric patiets (letter), Am J Emerg Med, 14: , Medical Clearace Checklist 1. Does the patiet have ew psychiatric coditio? Yes No 2. Ay history of active medical illess eedig evaluatio? 3. Ay abormal vital sigs prior to trasfer? 4. Ay abormal physical exam (uclothed)? 5. Ay abormal metal status idicatig medical illess? If o to all of the above questios, o further evaluatio is ecessary.

24 The Term Medically Clear Titialli, JE, Peacodk, FW, Wright, MA: Emergecy medical evaluatio of psychiatric patiets. A Emerg Med 1994; 23: Poor documetatio of medical examiatio of psychiatric patiets 298 charts reviewed i 1991 at oe hospital Physicia deficiecies was metal status i 20% Term medically clear documeted i 80% Titialli states the term Medically Clear should be replaced by a discharge ote History ad physical examiatio Metal status ad eurologic exam Laboratory results Discharge istructios Follow up plas Other use the term medically stable

25 Case #1 64 year old female is brought to the hospital for maic behavior. Patiet has multiple medical problems but o prior psychiatric history. What iformatio is eeded? Prior psychiatric history - oe History of medical problems DM, HTN, CVAs Use of drugs ad alcohol - Deies What to look for i the physical exam? Vital sigs tachycardia & hypertesive Focal deficits right sided weakess Sigs of itoxicatio Heighteed cosciousess What testig is idicated? CBC, electrolytes, thyroid, UDS, alcohol level EKG, CT sca head, CXR

26 Case #2 36 year old male with schizophreia was brought i by the family because he stopped takig his medicatio ad is gettig violet at home. What iformatio is eeded? Prior psychiatric history - Yes History of medical problems ocotributory Drug ad alcohol use admits to alcohol What to look for i the physical exam? Vital sigs ormal Metal status exam auditory halluciatios Physical exam uremarkable Sigs of itoxicatio oe What is testig is idicated? Noe He ow becomes more agitated What is the treatmet of choice?

27 Agitatio Assessmet How is Agitatio Assessed ad Graded? I kow it whe I see it Tools Agitated Behavior Scale 14 item observatio of behavior from abset to preset to a extreme degree Overt Aggressio Scale Assesses verbal aggressio, physical aggressio agaist objects, self, other people ad itervetios Richardso Agitatio Sedatio Scale Scored from combative to uarousable based o observatio PANSS (Positive ad Negative Sydrome Scale) Hostility, ucooperative, impulsivity, tesio & excitable Used i cliical trials

28 Level of Agitatio of Patiets Presetig to a Emergecy Departmet Zu, Prim Psych Of that total, 53 had o restraits, 47 had restraits. Two of the 47 restraied patiets o the ABS were rated severely agitated. The agitatio scales decreased over time i both groups

29 Reaso to treat agitated patiets Patiet distress Prevet progressio ad violece Up to 50% ED staff victims of violece Better able to assess the patiet Bider, Rl, McNeil, DE: Cotemporary practices i maagig acutely violet patiets i 20 psychiatric emergecy rooms. Psych Services 1999;50: of 20 medical directors stated that the patiets are so agitated that it is difficult to get vital sigs. 14 of 20 said the protocol was to physically restrai patiets ad medicate them prior to a medical work-up Begi therapeutic process Fishkid, AB: Agitatio II: De-escalatio of the aggressive patiet ad avoidig coercio. Emergecy Psychiatry, Collaborative iteractios Elicit iformatio Patiets say all they wat Iclude patiets i plaig Empathize

30 Treatmet Verbal de-escalatio Physical restraits Seclusio Chemical treatmet Combiatio

31 10 Domais of De-Escalatio AAEP: Verbal De-escalatio of the Agitated Patiet: Cosesus Statemet of the America Associatio for Emergecy Psychiatry BETA De-escalatio Work Group, West J Emerg Med 2012:13: Respect persoal space Do ot be provocative Establish verbal cotact Be cocise Idetify wats ad feeligs Liste closely to what the patiet is sayig Agree or agree to disagree Lay doe the law ad set clear limitatios Other choices ad optimism

32 Physical Restraits Alteratives to Restrait Use Dowey LV, Zu LS, Gozales SJ: Frequecy of alterative to restraits ad seclusio ad uses of agitatio reductio techiques i the emergecy departmet. Ge Hosp Psychiatry Nov-Dec;29(6): Surveyed a radom sample of ED ad all Psychiatric EDs i the coutry. Almost all EDs (90%) ad Psych EDs use alteratives (98%) Alteratives used Frequecy Effectiveess Verbal 84% 36% Oe to oe 79% 48% Decrease i stimulatio 74% 15% Food or drik 69% 18%

33 Physical Restraits Complicatios of Patiet Restrait Zu, LS: Complicatios of Patiet Restraits, J Emerg Med 2003; 24: The purpose of the study was to determie the type ad rate of complicatios of patiets restraied i the ED over 1 year 221 patiets were restraied i the ED Mea of 4.78 hours - Rage.2-24 hrs Positio - Supie positio (87.1%) Chemical restraits were added (28.6%) Complicatio rate 5.4% No major complicatios such as death or disability

34 Seclusio Use i Emergecy Medicie Zu, LS ad Dowey, L : The use of seclusio i emergecy medicie. Ge Hosp Psych 2005; 27: Defied as ivolutary cofiemet of a patiet aloe i a room Survey study of a radom sample of 1067 US EDs medical directors 27.8% use seclusio Reasos ot to use seclusio Problems with physical plat 50.2% Cocer over safety 36.5% Too may regulatios 19.7%

35 Medicatio Recommedatios First Geeratio Ati-Psychotics AAEP: The Psychopharmacology of Agitatio: Cosesus Statemet of the America Associatio for Emergecy Psychiatry BETA De-escalatio Work Group, West J Emerg Med 2012:13: Geeral Use o-pharmacologic approaches first Use medicatio tailored to diagosis Adjust medicatio to level of agitatio First geeratio atipsychotics- Haloperidol ad Droperidol Miimal effect o vital sigs, aticholiergic ad iteractio with other atipsychotic meds Prologs QT iterval EPS/acute dystoic reactios i 6-20% Avoid IV use

36 Medicatio Recommedatios Secod Geeratio Atipsychotics AAEP: The Psychopharmacology of Agitatio: Cosesus Statemet of the America Associatio for Emergecy Psychiatry BETA De-escalatio Work Group, West J Emerg Med 2012:13: Admiistratio optios Olazepie, Ziprosidoe, Aripiprazole IM & oral Risperidoe ad quetiapie oral Recommedatios No head to head trials Risperidoe=haloperidol+lorazepam - IM Risperidoe=haloperidol = Olazepie- oral Aripiprazole, Quetiapie ad Clozapie ot recommeded

37 Ketamie Use i Agitated Patiets Use i EMS Eveso, JE, Aberathy, MK: Ketamie for prehospital use: ew look at a old drug. Am J Emerg Med 2007;25, Give to 40 agitated patiets Recommed use eve i head trauma patiets 1-5 mg/kg IV or IM with o adverse evets Use i the ED Ridell, J et al: Ketamie as a first lie treatmet for severely agitated emergecy departmet patiets. Am J Emerg Med 2017;35: Compared ketamie to bezo, haloperidol, ad haldol+bezo Ketamie 4 mg/kg IM or 1mg/kg IV Ketamie group were o loger agitated tha other other medicatio 2 ketamie, 1 each of the other groups were itubated

38 Use of Atihistamies Questioable use as solo aget For use with typical ati-psychotics To prevet acute dystoic reactios Studies doe o daily use o adverse evets More frequet i iitiatio of treatmet More frequet i youg males Icreases sedatio Ca cause paradoxical agitatio No good evidece for its routie use i ED

39 Need for Bezos i Combiatio Gillies, D et al: Bezodiazepies aloe or i combiaito with atipsychotic drugs for acute psychosis. Cochrae Database Syst Rev 2005:19 Reviewed 11 studies of 648 patiets Compariso of bezos aloe Sedatio equally prevalet Fewer people remaied excited after 24 hours with bezos Similar icidece of adverse evets Compariso of bezos to atipsychotics Higher icidece of extrapyramidal symptoms i atipsychotic group Combiatio treatmet thought to have higher icidece of over sedatio

40 Oral or IM Gault. TI: Are oral medicatios effective i the maagemet of acute agitatio. J Emerg Med Structured literature review 11 articles were used with ED time course Oral medicatios are as effective as IM i rapid reductio of psychotic agitatio Cosider risperidoe 2mg with or without lorazepam 2 mg or olazepie 10mg Did ot iclude extreme agitatio

41 QT Prologatio Glassma, AH, Bigger: Atipsychotic drugs: prologed QTc iterval, torsade de poites, ad sudde death. Am J Psych 2001;158: Prologatio of QT (msec) Ziprasidoe 20.3 Quetiapie 14.5 Droperidol Risperidoe 11.6 Olazapie 6.8 Thioridazie 35.6 Haloperidol 4.6 Fidigs Thioridazie is most marked associated with Torsade Haloperidol ca cause Torsade ad sudde death Olazapie, Risperidoe ad Quetiapie does ot cause Torsade Cocers Youg patiets who have family history of prologed QT Older patiets with kow heart disease or drugs that prolog QT eed a pretreatmet EKG Hypokalemia may predispose to QT prologatio

42 Icreased violet behavior Herrera, JN, Sramek, JJ, Costa, JF et al: High potecy euroleptics ad violece i schizophreics. J Nervous Metal Dis 1988; 176: male schizophreic patiets resistat to previous euroleptic treatmet Compariso of Haloperidol to Clozapie or Chlorpromazie Sigificatly more violet episodes occurred with haloperidol tha other meds or placebo Could this be from akathisia or drugiduced behavioral toxicity

43 Medicatio Recommedatios Due to Itoxicatio AAEP: The Psychopharmacology of Agitatio: Cosesus Statemet of the America Associatio for Emergecy Psychiatry BETA De-escalatio Work Group, West J Emerg Med 2012:13: Drugs Most recreatio drugs-bezodiazepies Chroic amphetamie use with psychotic symptoms-2 d geeratio atipsychotic + bezo Alcohol Acute itoxicatio Avoid bezodiazepie Cosider haloperidol, olazepie or risperidoe Withdrawal-Bezodiazepie

44 Special populatios Pregat High-potecy covetioal atipsychotics (lack of kow teratogeicity) Alshuler, LL, Cohe, L, Szuba, MP, et al: Pharmacologic maagemet of psychiatric illess durig pregacy: dilemmas ad guidelies. Am J Psych 1996;153: Childre Bezodiazepies or butyropheoes Dorfma, DH, Kaster, B: The use of restraits for pediatric psychiatric patiets i emergecy departmets. Ped Emerg Care 2004;20: Atypical Atipsychotics - risperidoe or olazapie Alle, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatmet of behavioral emergecies. Post Grad Med 2001; S1-88.

45 Agitatio Treatmet i Demeted Elderly D.P. Devaad, M.D;.Agitatio i the Elderly with Demetia Psychosis, Agitatio, ad Atipsychotic Treatmet i Demetia. Black boxed warig icreased mortality risk was based o a meta-aalysis of placebo-cotrolled short-term trials of atipsychotics Haloperidol has a higher rate of mortality tha atypical atipsychotics Risperidoe is approved i Germay for the treatmet of behavioral demetia Completely avoidig the use of atipsychotics is ot feasible Start the medicatio at a low dosage ad to raise the dosage slowly

46 score Resposiv eess +3 combative, violet, out of cotrol Speech cotiual loud outbursts Chemical Treatmet +2 very axious ad agitated +1 axious/res tless 0 awake ad calm/coope rative -1 asleep but rouses if ame called -2 respods to physical stimulatio -3 o respose to stimulatio loud outbursts ormal / talkative ormal slurrig or promiet slowig few recogizabl e words il

47 Case #2 36 year old male with schizophreia was brought i by the family because he stopped takig his medicatio ad is gettig violet at home. He ow becomes more agitated What is the treatmet of choice? De-Escalatio was usuccessful SAT score of +3 Patiet give Haloperidol ad Lorazepam Agitatio re-evaluated i oe hour Patiet had score of 0

48 Take Home Poit Testig Test idicated for patiets with ew oset of psychiatric illess Testig rarely idicated for patiets with kow psychiatric illess The use of a protocol is useful for the medical clearace process Assess level of agitatio Use de-escalatio, if possible Determie treatmet based o uderlyig coditio ad level of agitatio

49 Cotact Iformatio Leslie Zu, MD