Pearls for Psychiatric Emergencies

During our most recent conference, Dr. Corey Goldstein, one of our emergency medicine faculty who is also trained in psychiatry, gave an informative talk on how to approach patients presenting with anxiety related disorders – including generalized anxiety disorder, panic attacks/panic disorder, PTSD, and OCD).  He finished with an update on the treatment of acutely agitated patients and discussed the Beta Guidelines, developed by the American Association of Emergency Psychiatry. 

In this week’s blog post, I will cover three takeaways and learning pearls from this lecture that can easily be implemented into my next ED shift.  These can be generalized out to all patients who present with a psychiatric complaint. 

#1 Get your own history, do a focused physical exam, and don’t forget to do a basic mental status exam.

• Taking time to obtain and process a good H and P, and the patient’s mental status exam can aid in developing an appropriate assessment, plan, and disposition. You may gain critical information to help determine if this is an organic disease process or a primary psychiatric disorder. You may be able to better determine and justify if the patient is a threat to themselves, a threat to others, or is unable to care for themselves (gravely disabled). This is particularly important in care settings that do not have 24/7 psychiatric coverage.  The emergency physician should do their own history, physical exam, mental status exam, and work with the crisis evaluator to gather additional information in order to properly formulate a plan.  In addition, collateral history may be a necessity to develop a disposition.   

#2 In the right circumstance, consider prescribing “bridging” medications upon discharge from the ED, utilizing appropriate discussion with a follow up provider.  Generally, this will be a primary care physician, psychiatrist, or psychiatric APP. 

• Proper evaluation of patients with psychiatric complaints provides the emergency physician an opportunity to intervene and help lower risk patients who will be discharged and are awaiting follow up. This may include medication management and/or referral to psychotherapy.  As above, the crisis evaluator or social worker can be of major help in this process. 

• Additionally:
  • When the diagnosis is unclear, if the EP does not feel comfortable prescribing benzodiazepines, or if the patient is unable to take a benzodiazepine, newer generation antipsychotic medications such as low dose olanzapine (2.5mg to 5mg at night) or quetiapine (50mg to 100mg at night), may be reasonable as “off label” and brief interventions for patients who are acutely anxious or having more significant difficulty with sleep.  As always, some sort of follow up should be clearly documented.  Always discuss sedation as a likely adverse effect and caution against driving, as well as the more uncommon but possible adverse effect of EPS such as akathisia. 
  • For patients without a substance use disorder history, we may consider a very short course of benzodiazepines for severe anxiety until reliable follow up.  This should only be done with a significant comfort level by the EP.  Be mindful that regular use of benzodiazepines can quickly cause physical dependence and the prescription should clearly state that the patient should not drive or make important decisions after taking one.  If a benzodiazepine is appropriate, Clonazepam at lower dose (0.25mg to 0.5mg PRN) is optimal as it is longer acting and may have lower rates of abuse.  Never give benzodiazepine prescriptions to patients concurrently taking opioid medications and always look at the Prescription Monitoring Program data to ensure that a benzodiazepine is appropriate. 

#3 Utilize the Beta Guidelines, developed by the American Association of Emergency Psychiatry for patients who need treatment for acute agitation – instead of reflexing to the old 5 and 2. 

• The general Beta Guideline recommendations include:
  • First, attempt to diagnose the most likely cause of their agitation and target medication to that disease.
  • Verbal escalation and reducing environmental stimulation should always be attempted if possible and safe.
  • Medications should be used to calm patients, not induce sleep.
  • Patients should be involved in the process of selecting medications, if possible.
  • Oral medications are preferred if the patient is cooperative.

When pharmacologic restraint is required, select medications based on the patient presentation. I have include a flow sheet below.

• Agitation due to intoxication of most recreation drugs besides alcohol
  • Benzodiazepines are considered first line
  • Second generation antipsychotic can be considered if benzodiazepines are insufficient

• Agitation due to intoxication with ETOH
  • First or second generation antipsychotic
    • Haloperidol, Risperidone or Olanzapine PO
    • Haloperidol, Olanzapine or Ziprasidone IM
  • Avoid benzodiazepines if possible

• Agitation due to psychiatric Illness
  • Second generation antipsychotic
    • Risperidone or Olanzapine PO first line
    • Olanzapine or Ziprasidone IM second line
  • If initial antipsychotic is insufficient, addition of benzodiazepine is preferred to additional doses of the same antipsychotic

• Agitation in a patient with known dementia or delirium
  • Second generation antipsychotic
    • Risperidone or Olanzapine PO first line
    • Olanzapine or Ziprasidone IM second line
  • Avoid benzodiazepines

A few final important notes to remember when managing a patient with acute agitation:

• Safety is number one priority
• Have a plan when entering the room
• Remember it may take up to 15 minutes to see affects from these IM drugs
• Many people will de-escalate with either a benzodiazepine OR and antipsychotic and most patient don’t need both

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Thank you to Dr. Goldstein for a great lecture and helping me edit this post.