What is the initial approach to managing medical emergencies in psychiatry?

Initial Approach to Managing Medical Emergencies in Psychiatry

All patients presenting with psychiatric complaints in the emergency department require a focused medical assessment to exclude medical etiologies and identify acute medical conditions requiring treatment, but routine laboratory and radiographic testing should NOT be performed unless guided by specific findings on history and physical examination. 1

Step 1: Immediate Safety Assessment and Stabilization

• Ensure safety first: Assess immediate risk to patient, staff, and others before proceeding with any evaluation 2, 3
• Maintain least restrictive setting: Use verbal de-escalation as first-line intervention, reserving chemical or physical restraints only when verbal methods fail 2
• Assess vital signs immediately: Abnormal vital signs (fever, tachycardia, hypertension, hypotension) mandate medical workup regardless of psychiatric presentation 1

Step 2: Focused Medical Assessment (NOT "Medical Clearance")

The term "medical clearance" is problematic and should be replaced with "focused medical assessment" - a process to exclude medical causes of psychiatric symptoms and detect acute illness requiring treatment 1

Key Historical Red Flags Requiring Medical Workup:

• New-onset or first-episode psychiatric symptoms (highest risk for underlying medical cause) 1
• Acute change in chronic psychiatric symptoms 1
• Altered mental status or disorientation (60% had medical etiology in one study) 1
• Age >65 years 1
• No prior psychiatric history 1
• Substance abuse history 1
• New medical complaints 1

Physical Examination Priorities:

• Cognitive assessment: Screen for delirium vs. dementia vs. functional psychiatric disorder 1
• Neurological examination: Look for focal deficits, movement disorders, signs of increased intracranial pressure 1
• Search for toxidromes: Examine pupils, skin, mucous membranes, vital signs for patterns suggesting intoxication or withdrawal 1
• Assess for self-injury: Thorough skin examination for cutting, ligature marks, injection sites 1

Step 3: Selective Laboratory and Imaging

When patients are clinically stable (alert, cooperative, normal vital signs, noncontributory history/physical, and typical psychiatric symptoms), routine laboratory testing should NOT be performed 1

Order Testing ONLY When:

• Abnormal vital signs present 1
• Altered mental status or disorientation 1
• First psychiatric presentation 1
• Concerning findings on history or physical examination 1
• Elderly patients with new symptoms 1

Evidence Against Routine Testing:

• False positive results are 8 times more frequent than true positives in routine screening 1
• Only 1.8-2% of routine tests reveal clinically significant abnormalities not predicted by history/physical 1
• 4% required acute medical treatment within 24 hours, and 83% of these were identifiable by clinical evaluation 1

Brain CT Scanning:

• NOT routinely indicated for psychiatric presentations without focal neurological findings 1
• One study found abnormalities in only 5% of psychiatric patients, with none relevant to their condition 1
• Consider radiation exposure risks, especially in pediatric patients 1

Step 4: Psychiatric Risk Assessment

Suicide Risk Evaluation:

• Interview patient and collateral sources separately and together - patients frequently minimize symptoms 1
• Assess current suicidal ideation, intent, plan, and access to means 1
• Evaluate protective factors: Support system, ability to engage in safety planning, follow-up availability 1
• High-risk criteria requiring hospitalization: Persistent desire to die, severe hopelessness, inability to safety plan, inadequate support/monitoring, high-lethality attempt with clear expectation of death 1

Critical Pitfall to Avoid:

NEVER use "no-suicide contracts" or "no-harm agreements" - these have no proven efficacy, may damage therapeutic alliance, and provide false reassurance to clinicians 2

Step 5: Acute Agitation Management

Verbal De-escalation (First-Line):

• Always attempt verbal intervention first before chemical or physical restraint 2, 4
• Maintain calm demeanor, provide space, offer choices, validate feelings 2

Pharmacological Intervention (Second-Line):

Oral medications are strongly preferred over intramuscular when patient cooperation allows 4

For Acute Agitation:

• Benzodiazepines alone are first-line for agitation without clear psychotic etiology 4
• Combination of benzodiazepine + antipsychotic for suspected schizophrenia, mania, or psychotic depression 4
• Olanzapine IM 10 mg (or 5-7.5 mg when clinically warranted) for acute agitation in schizophrenia or bipolar mania, maximum 3 doses 2-4 hours apart 5
• Assess for orthostatic hypotension before each subsequent IM olanzapine dose 5

Physical Restraint (Last Resort):

• Use only when verbal and chemical interventions fail 2
• Restraints increase morbidity and mortality risk 2
• Requires frequent reassessment and monitoring 2

Step 6: Disposition Decision

Criteria for Psychiatric Hospitalization:

• Severe behavioral escalation unresponsive to ED interventions 2
• Active suicidal ideation with inability to engage in safety planning 2
• Acute psychotic decompensation impairing safety 2
• Gravely disabled (unable to care for basic needs) 1

Involuntary Hold Criteria (State-Specific):

• Mental disorder present AND immediate risk of harm to self or others 1
• Familiarize yourself with specific state laws regarding duration (typically 72 hours, range 1-30 days) 1

Discharge Planning for Lower-Risk Patients:

• Schedule first outpatient appointment within 48-72 hours for high-risk patients 2
• Provide crisis resources: Local crisis center numbers, National Suicide Prevention Lifeline (988), Crisis Text Line 2
• Means restriction counseling: Remove firearms, secure medications, lock up knives 1
• Firearms in home double youth suicide risk - strongly encourage temporary removal to relative/friend/law enforcement 1

Special Population Considerations

Pediatric Patients:

• Systematically screen for abuse - crisis situations elevate risk 2
• Obtain collateral information from caregivers, schools, other sources 1
• Interview adolescents separately after discussing confidentiality limits 1
• Avoid routine brain CT due to radiation concerns 1

Elderly Patients:

• Higher risk for medical causes of behavioral changes 1
• Screen for delirium systematically using validated tools 1
• Consider medication side effects and interactions 1

Common Pitfalls to Avoid

• Do not use "medical clearance" terminology - implies different things to different providers 1
• Do not order routine laboratory panels on stable psychiatric patients 1
• Do not rely on no-suicide contracts 2
• Do not skip collateral information gathering - patients minimize symptoms 1
• Do not discharge without means restriction counseling for suicidal patients 1
• Do not breach confidentiality without explicit consent except for imminent danger 1