Chapter 185. Emergency Assessment and Stabilization of Behavioral Disorders

In the last 2 decades, mental health-related visits to emergency departments (ED) in the United States increased 38% to 23.6 per 1000 population.

Suicidal patients are often forthcoming about their intentions for self-harm. The patient's intentions may be more difficult to infer after a nontraumatic suicide attempt and if the patient has an altered level of consciousness than after a self-inflicted traumatic injury. Patients with multiple seemingly unrelated somatic complaints may be depressed. High- and low-risk profiles for suicide risk are summarized in Table 185-1. Medication overdose is the most common type of suicide attempt.

Homicidal or violent patients tend to pose little diagnostic dilemma to the clinician. They may openly assert their harmful intentions. Their language may contain profanity, escalate in volume, and be rapid or pressured. Mannerisms suggestive of a potentially violent patient include restlessness, pacing in the examination room, clenched fists, acts of violence directed toward inanimate objects in the room, and hypervigilance.

Differentiating medical (organic) and psychiatric etiologies for abnormal behavior is essential. Evaluation includes a detailed history of present illness, past medical and psychiatric history, medication history, social history, and a physical examination, including a thorough neurologic and mental status examination. Important historical information includes the presence of previous psychiatric illness, fever, head trauma, infections, ingestion of medications or legal and illegal substances, disorientation or confusion, impaired speech, syncope or loss of consciousness, headaches, and difficulty performing routine tasks. Inquire about suicidal or homicidal intent. Obtain a third-party account of the patient's behavior, changes in behavior and normal level of function.

Mental status examination should note physical appearance, affect, orientation, speech pattern, behavior, level of consciousness, attention, language, memory, judgment, thought content, and perceptual abnormalities. Findings such as abnormal vital signs, disorientation with clouded consciousness, abnormal findings on mental status exam, recent memory loss, age > 40 without prior history of psychiatric disease, focal neurologic signs, visual hallucinations, and psychomotor retardation may indicate an organic etiology for the behavior and serve as a guide for further evaluation. Visual hallucinations are more suggestive of a medical etiology, whereas auditory hallucinations support a psychiatric etiology.

Multiple reversible medical conditions can result in the acute onset of a behavioral abnormality. Look for signs of trauma, infection, substance abuse, intoxication or withdrawal, metabolic and endocrine disorders, and disorders of the central nervous system. The patient's laboratory evaluation should be directed toward discovering or confirming suspected abnormalities. Oxygen saturation on room air and glucose levels should be quickly assessed. Additional tests that can be useful depending on the clinical situation include a complete blood count, serum electrolytes, creatinine, hepatic enzymes, T4 level, TSH, ethanol, urinalysis, urine drug screen, pregnancy test, arterial blood gas analysis, cerebrospinal fluid analysis, electrocardiogram, and computed tomography or magnetic resonance imaging of the brain. Salicylate and acetaminophen levels also are useful in the suicidal patient.

1. The first priority is safety and stabilization, including attention to airway, breathing, and circulation. Contain violent and dangerous psychotic patients to ensure their safety and the safety of everyone else in the ED. Agitated and violent patients may require sedation and/or restraints to avoid self-injury and harm to nearby individuals. Figure 185-1 suggests an algorithmic approach for safe chemical sedation.

2. Suicidal, homicidal or violent patients should be disrobed, gowned and searched for potentially dangerous items.

3. Approach the violent patient with a nonthreatening voice, avoid excessive eye contact, keep the exit from the room accessible, and enforce acceptable limits of behavior.

4. Determine if the patient needs to be detained for emergency evaluation.

5. Proceed with medical and psychiatric evaluation. Treat medical conditions as indicated.

6. Assess severity of psychiatric disease and determine the need for psychiatric consultation.

7. Patients judged to be at high risk of harming themselves or others or those who are unable to care for themselves require admission to a psychiatric facility.

8. Disposition decisions for moderate-risk patients are usually made in consultation with a psychiatric consultant. Ensure close psychiatric follow-up and good social support, including someone to stay with the patient, prior to discharge.