Rosen & Barkin's 5-Minute Emergency Medicine Consult (583 page)

• Screen for psychosis, including onset, duration, triggers, and content:
  
  • Delusions:
    
    • “Do you feel anyone is trying to harm you or that you are being followed?”
      
    • “Is anyone trying to send you messages, steal, control, or block your thinking?”
      
  • Hallucinations:
    
    • “Do you ever see or hear things that other people cannot see or hear?”
      
    • “Do you ever hear voices telling you to do things such as to harm yourself or to harm others?”
      
• Suicidal or homicidal behavior or threats
  
• Past medical and psychiatric history
  
• Social situation and ability to care for self
  
• Recent use, increase or cessation of medications, drugs, or alcohol
  
• Obtain history from friends, family, and treaters
  

Look for signs of a medical etiology:

• Vital signs
  
• Eye exam (pupils, EOM, fundi)
  
• General exam with particular attention to the signs and symptoms of endocrine, liver, and renal disease
  
• Neurologic exam, including cognitive exam
  
• Careful assessment for signs of delirium
  

The workup is case specific and primarily based on the suspected etiology

• Electrolytes, BUN, creatinine, glucose, calcium
  
• Toxicology screen
  
• CBC with differential
  
• TSH
  
• Urinalysis
  
• Further specific studies should be guided by the suspected underlying etiologies
  

Consider head imaging for new-onset psychotic symptoms of unclear etiology, especially in setting of focal neurologic symptoms.

When clinically warranted consider:

• Lumbar puncture
  
• EEG
  
• EKG (monitor QT)
  

See Etiology.

TREATMENT

• Patients can display unpredictable and violent behavior toward themselves and others
  
• Patients may require police presence or restraints to maintain safety
  
• Local laws vary regarding involuntary restraint
  

• Safety of patient and staff is paramount and may require presence of security
  
• Behavioral interventions should be used first
  
  • Provide a calm, containing environment
    
  • Remove all potentially dangerous items
    
  • Use a reassuring voice and calm demeanor to set boundaries and verbally redirect
    
• If safety is a concern, patient needs to be under constant observation
  
• Physical or chemical restraints as necessary
  

• If a nonpsychiatric etiology is suspected, identify and treat underlying medical condition
  
• If a psychiatric etiology is suspected, consider psychiatric consultation or referral
  
• Acute agitation is reduced with antipsychotics:
  
  • Encourage voluntary PO medications prior to IM administration
    
  • Avoid polypharmacy
    
• Rapid tranquilization may be achieved with the addition of a benzodiazepine
  
• Monitor for and treat adverse effects from antipsychotic medications:
  
  • Extrapyramidal symptoms (dystonia, akathisia, pseudoparkinsonism, and tardive dyskinesia)
    
  • Neuroleptic malignant syndrome is a life-threatening complication:
    
    • Characterized by hyperthermia, muscle rigidity, autonomic instability, and altered consciousness
      

• 1st line antipsychotics:
  
  • Haloperidol: 2–10 mg PO/IV/IM, repeat q20–60min prn to max. 100 mg/d; elderly 0.5–2 mg/dose
    
    • Commonly augmented with lorazepam
      
• 2nd line antipsychotics:
  
  • Aripiprazole: 2–15 mg PO/IM, may repeat q2h prn to max. 30 mg/d
    
  • Chlorpromazine: 25 mg PO/IM, repeat 25–50 mg q60min prn to max. 1,000 mg/d. Caution: Sedating, postural hypotension, do not use in elderly
    
  • Olanzapine: 2.5–20 mg PO/IM, may repeat dose q2–4h prn to max. 20 mg/d; elderly 2.5–5 mg/dose. Caution: Concurrent use of IM olanzapine and IV benzodiazepines may increase risk of cardiopulmonary collapse
    
  • Risperidone: 1–2 mg PO, may repeat 2 times; elderly 0.25–0.5 mg/dose. Caution: Orthostatic hypotension
    
  • Quetiapine: 25–50 mg PO BID, increase by 100 mg/d to max. 800 mg/d; elderly 12.5–25 mg/dose, increase by 25–50 mg/d
    
  • Ziprasidone: 20–40 mg PO BID, max. 80 mg PO BID; 10 mg IM q2h or 20 mg IM q4h prn to max. 40 mg/d IM, no more than 3 days. Caution: Monitor QT
    
• Benzodiazepines:
  
  • Lorazepam to augment tranquilization: 1–2 mg PO/IM/IV; elderly 0.25–0.5 mg PO/IM/IV
    

Black box warning: Elderly patients with dementia-related psychoses treated with antipsychotic drugs are at increased risk of death.

FOLLOW-UP

• If nonpsychiatric etiology, admit to appropriate medical service
  
• If psychiatric etiology and patient is medically stable, patient may require admission to a psychiatric hospital if patient:
  
  • Is a danger to self or others
    
  • Is gravely disabled and unable to care for self due to psychosis
    
  • Has new-onset psychosis and medical etiology has been ruled out
    
• Criteria for involuntary hospitalization vary
  

• Patient is not a danger to self or others and is able to perform activities of daily living
  
• Psychotic symptoms resolved after causative medical issue addressed and patient is medically stable for discharge
  

Consider psychiatric consultation for complicated cases or for psychiatric admission.

• Plan appropriate outpatient medical follow-up
  
• In patients with psychiatric disorders not requiring admission, plan outpatient psychiatric follow-up within 1 wk
  
• Consider referral for detoxification in patients with problems related to substance use
  

• Psychotic symptoms should be evaluated for treatable medical causes and not assumed to be solely psychiatric in nature even in patients with known mental illness
  
• Visual, olfactory, gustatory, or tactile hallucinations should prompt medical workup
  
• Avoid using IM olanzapine with IV benzodiazepines as this increases risk for cardiopulmonary collapse
  
• Patients who have recently started or increased their antipsychotics who present with fever, rigidity, autonomic instability, and mental status changes should be assessed for neuroleptic malignant syndrome
  

• Byrne P. Managing the acute psychotic episode.
  BMJ.
  2007;334(7595):686–692.
  
• Mathias M, Lubman DI, Hides L. Substance-induced psychosis: A diagnostic conundrum.
  J Clin Psychiatry.
  2008;69:358–367.
  
• Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: Consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup.
  West J Emerg Med
  . 2012;13(1):3–10.
  
• Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: Consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup.
  West J Emerg Med
  . 2012;13(1):26–34.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Delirium
  
• Dystonic Reaction
  
• Neuroleptic Malignant Syndrome
  
• Psychosis, Medical vs. Psychiatric
  
• Schizophrenia
  
• Violence, Management of
  

CODES

• 292.9 Unspecified drug-induced mental disorder
  
• 298.8 Other and unspecified reactive psychosis
  
• 298.9 Unspecified psychosis
  

BASICS