Education Committee Newsletter Psychiatric Considerations Winter 2014

Bipolar Disorder: Dan

Sullivan
A mood disorder also known
as manic depression, bipolar
affective disorder or manic-
depressive disorder
A disorder of the brain which
affects ones mood, energy
and activity level
Characterized by elevated
mood swings known as
mania to severe depression
Bipolar disorder can be
subdivided as follows:
a. Bipolar I Disorder
Individuals have mood
swings severe enough
to interrupt daily life
b. Bipolar II Disorder
Individuals experience
a milder form of mania,
known as hypomania;
the lows of depression
usually last longer than
those of hypomania
c. Cyclothymic Disorder
Individuals who
experience hypomania
and depression, but the
highs and lows are not
as severe as with other
types of Bipolar
Disorder
Individuals experiencing a
manic episode may have the
following signs and
symptoms: feelings of
euphoria, agitation,
decreased sleep, rapid
speech, restlessness,
increased use of drugs
and/or alcohol, poor
judgment and high-risk
behavior
Individuals experiencing a
depressive episode may have
the following signs and
symptoms: sadness, feelings
of hopelessness, difficulty
concentrating, fatigue,
difficulty sleeping and
suicidal thoughts
Genetic component tends
to run in families; individuals
who have a parent or sibling
with bipolar disorder are at a
higher risk for developing the
disorder
Bipolar disorder typically
develops in individuals who
are in their teenage or young
adult years
Substance abuse, post-
traumatic stress disorder
(PTSD), attention
deficit/hyperactivity disorder
(ADHD) and other health
problems such as obesity
may occur in individuals with
bipolar disorder
Treatment includes
psychotherapy and
medications
Common medications used
to treat bipolar disorder
include lithium, valproic acid
(Depakote), lamotrigine
(Lamictal), gabapentin
(Neurontin), topiramate
(Topamax) and
oxcarbazepine (Trileptal).
Others include olanzapine
(Zyprexa), aripiprazole
(Abilify), quetiapine
(Seroquel) and risperidone
(Risperdal).

Care of the Alcohol Use
Disorder Patient: Becky
Davis
One of our most complicated and
difficult patients we take care of in our
emergency department is the Alcohol
Use disorder patient. The diagnostic
criteria for this disorder is a primary,
chronic disease with genetic,
psychosocial, and environmental factors
influencing its development and
manifestations. The disease is often
progressive and fatal. The condition is
usually characterized by the following
characteristics: impaired control over
drinking, preoccupation with alcohol,
use of alcohol despite adverse
consequences, and distortion of
thinking. The prevalence for alcohol
abuse is greatest between the ages of
30 to 64, but ranges all ages.
Providing quality and
compassionate care and follow up for
these patients is a very complex
problem for health care staff. Excessive
drinking leads to a mortality of
approximate 80,000 deaths annually
which is the 3
rd
leading cause of
preventable death. Trauma is
frequently involved with the
presentation of an alcohol use disorder
patient to the Emergency department.
Due the complexity of patients
problem it is often difficult to perform a
thorough medical and psychiatric exam.
However it is imperative to attempt to
cut through all the barriers and get a
good medical picture of what is
occurring with the patient. Looking for
signs of alcoholic withdrawal, physical
trauma, and psychological problems are
imperative to preventing the morbidity
of patients. We all know of the
alcoholic who come in with a fall are
not waking up normally and turn out to
have a huge intracranial bleed due to
trauma. Laboratory test is needed to
identify the levels of intoxication, other
substances ingested, and liver
involvement. CTs and x rays are
frequently needed to identify injuries
that the intoxicated person is incapable
of identifying himself due to the level of
alcohol in his system.
Of primary importance for all
staff and members taking care of these
individuals is to provide for our own
safety and care of our team members.
Frequently these patients are
unpredictable, volatile and can cause
harm to staff and themselves. Their
actions can be frequently set off by
nonverbal actions by team members or
verbal exchanges. Security is a vital
team member and should be accessed
early with the care of the alcoholic
patient if there is any sign of problem.
Non crisis intervention techniques are a
great tool for deescalating situations or
the help of another team member if the
patient targets you as a person to place
his anger or violent actions toward.
The involvement of PSL occasionally
can be utilized when the patient is
clinically sober. Due the chronic
problems of Alcohol Use Disorder
patient it is important to try to involve
case management or the new B2C staff
to help with care to keep the patient
from falling in the abyss.
Documentation is important to
watch the trending of the vital signs
with hypertension and tachycardia
being harbingers of alcohol withdrawal.
A CIWA found in the Adult assessments
is imperative for continuity of care. A
psychosocial assessment and what
resources are utilized presently and/ or
are available to the patient helps with
the final discharge and placement of the
patient.
One of the most important
aspects in the care for these patients is
having a team effort so that you are not
alone in caring for these complicated
patients. Working to provide quality
care and safe care while maintaining our
resiliency and watching out for
compassion fatigue or burnout should
be our goal.
Education Committee Newsletter Psychiatric Considerations Winter 2014


Psychosis: Erin Pillette
According to Wikipedia, Psychosis
comes from the Greek psyche for
mind/soul and osis for abnormal
condition or derangement. Psychosis is
the umbrella term used until other
mental health disorders have been
diagnosed such as bipolar or
schizophrenia. The National Institute of
Health via Medline Plus and PubMed
websites state a number of medical
problems can cause psychosis including:
alcohol and certain illegal drugs, brain
diseases, brain tumors or cysts,
dementia, HIV, some prescription drugs,
some types of epilepsy, stroke.
Common causes of psychosis are found
in schizophrenic patients, bipolar and
severe depression patients as well as
some that have personality disorders.
The most common symptoms of
psychosis are delusions, hallucinations
and disorganized speech and thought
process those patients who present
with word salad or flight of ideas. In
most patients, lab tests are not
definitive, although some prescription
drugs and illicit drugs can be tested to
rule out those as being the root cause.
Typical tests that are ordered for
patients who present with psychotic
symptoms include, but are not limited
to, electrolye and hormone levels,
syphilis and other infectious diseases,
urine and blood drug screens, and a MRI
of the brain. There are several
treatment options. One treatment is
medication through antipsychotic drugs
orally or intramuscularly with or without
hospitalization. A second treatment is
cognitive behavior therapy as well as
family therapy including animal-
assisted therapy. Electroconvulsive
therapy can be used when other
treatments are rendered ineffective.
The prognosis for these patients
depends on the origin of the psychosis
what is causing this breakdown. Some
patients need life-long treatments as
others only need treatment for a brief
time. The main complication of
psychosis is when a patient is no longer
able to care for themselves related to
the psychosis preventing them from
normal activities of daily living.
Prevention of use of alcohol and/or
illicit drugs can help to avoid the
symptoms of psychosis.
Overdose: Ryan Morrissette
An OD (overdose) occurs when any drug
dose that is taken in a large enough to
be toxic to the body or vital
functioning.
1
Another definition is,
when a drug is eaten, inhaled, injected,
or absorbed through the skin in
excessive amounts and injures the
body.
2
This may occur suddenly, when a
large amount of the drug is taken at one
time, or gradually, as a drug builds up in
the body over a longer period of time.
Prompt medical attention may save the
life of someone who accidental or
deliberately takes an overdose.
1

STATS
The CDC (Center for Disease Control and
Prevention) reports when death occurs
from a drug overdose approximately
75% involved opioid analgesics, and that
approximately 30.1% of deaths, patients
had also taken benzodiazepines.
2
NCHS
(National Center for Health statistics)
data revealed that the number of
people dying from drug overdoses
progressively rose for an 11-year period
through the end of 2010, with
prescription opioid painkillers being the
main drive behind the increase.
2
In
58% of studied cases, other medications
are identified, as in poly-
pharm(aceutical) ODs.
3
Intentional
suicide only accounts for approximately
17% of pharmaceutical overdose where
75% were considered unintentional.
3

However, the number of successful
suicides by overdose for patients age
25-64 caused more deaths than motor
vehicle traffics crashes.
2

COMMON DRUGS
People will commonly abuse the
prescription and illicit drugs we
normally think of as in opiates, cocaine,
amphetamines, marijuana, barbiturates,
benzodiazepines, however many other
drugs can be much more serious and
still quite prevalent. Other medications
include antipyretics/inflammatory,
antihistamines, antidepressants,
antihypertensives, household products,
and probably most often ethyl alcohol
(EtOH). Each category presents
different risks, symptoms, and mortality
associated with toxic doses and can be
more lethal when combined. It is
important to quickly identify what the
patient took to most appropriately treat
and care for them.
MEDICAL CARE
The symptoms of drug overdose can
vary widely depending on specific drugs
used, but may include: abnormal pupil
size, agitation, bradycardia, convulsions,
death, delusional or paranoid behavior,
difficulty breathing, drowsiness,
hallucinations, hyper/hypotension,
nausea and vomiting, nonreactive
pupils, staggering or unsteady gait,
sweating or extremely dry hot skin,
tachycardia, tremors, unconsciousness,
violent or aggressive behavior.
1

First, make sure you are safe and others
are safe before providing emergency
medical care. Always begin with airway,
breathing, then circulation per ACLS
protocols and algorithms. If the patient
is having seizures, administer
anticonvulsant. Try to identify causative
agent or agents to treat appropriately
and seek expert consultation with
toxicologist and National Poison Control
Center (1-800-2222-1222).
1
Consider
getting professional psychiatric
resources and assessment for patient.
Continuously reevaluate patient and
vital signs for further treatment and
interventions as needed.
Self- Mutilation (Self
Harm)What is it?-Kellie
Callahan
Self-mutilation or self-harm is defined
as any intentional injury to ones own
body. Usually, self-injury leaves marks
or causes tissue damage. Many of
these behaviors occur alone, and
attempt to be secretive from others
finding out. The following are examples
of self-injury behaviors:
*Cutting
*Burning or Branding
*Excessive body piercing/tattooing

*Picking at skin (scabs, preventing
wounds to heal)
*Hair pulling (trichotillomania)
*Head-banging
*Hitting
*Bone breaking
Who is most likely to engage in Self-
Mutilation?
Unlike other mental disorders or
behavior problems, self-mutilation
occurs in many different socioeconomic
status, race, religion, age or education.
Education Committee Newsletter Psychiatric Considerations Winter 2014


Self-mutilation is a release of anxiety or
release of stress to the individual.
Self-mutilation normally starts in early
adolescent females, those who have a
history or sexual, emotional or physical
abuse. Those who have poor coping
skills with family or regular life stressors
tend to engage in such behaviors.
Warning signs of Self-Mutilation
*Covering arms/legs with clothing in
warm weather so injuries cant be
exposed
*Razors, sharp objects in ones
possession
*Low self-esteem/poor performance at
work or school
*Inattention to detail more than normal
*Family/Intimate relationship problems
What Do I do if I take care of patient
who is harming themselves?
*Request the patient contracts for
safety
*Remove harmful objects from the
patients possession
*Call security 8-777 and an initiate a
watch
*Speak to MD and PSL regarding
observations, request patient to have
further evaluation
Schizophrenia: Jennifer
Comer
The most common psychotic disorder
presenting to the emergency
department is schizophrenia.
Characterized primarily by delusions
and hallucinations, this disorder is one
of the most serious public health
problems in the word. This condition is
also marked by the presence of
disorganized thinking and speech, and
bizarre and inappropriate behavior.
Beginning usually in late adolescence or
early adulthood, the typical age group
that is seen in the emergency
department is adults. Common reasons
for schizophrenics to present to the ER
are worsening psychosis resulting from
stress, non-adherence to medication
regimen, suicidal behavior, violence,
and extrapyramidal side effects related
to medications. Suicidal behavior and
violence are usually related to paranoid
thinking. About 10% of people with
schizophrenia commit suicide. More
commonly, these patients make threats
of violence or have minor aggressive
outbursts rather than any seriously
dangerous behavior. The primary
concern in patients that present to the
Emergency Department with psychiatric
symptoms such as with schizophrenia is
stabilization of the acute psychiatric
condition. Then, evaluating the patients
presenting complaint. Since, frequently
these patients are unable to attend to
their basic needs, attention must also
be given to their physical status in
addition to their psychiatric problem.
Antipsychotic drugs, such as
haloperidol, usually will reduce the
positive psychotic symptoms such as
delusions or hallucinations. But, atypical
antipsychotics (aripiprazole, quetiapine,
risperidone, olanzapine, clozapine, and
ziprasidone) will usually effect these
positive symptoms and the negative
symptoms such as anhedonia (lack of
interest,) blunting of emotion,
inattention, and lack of volition.
EMTALA Transfer of Psych
Patient: Catherine
Bergstrom
Patients who are on an M1 hold should
be transferred to facility which
specializes in psychiatric care. EMTALA
transfers are done after the patient has
been stabilized (i.e. are no longer
floridly psychotic/combative and are
medically stable). Many times in the ED,
the psych social liason will facilitate the
transfer. The process is as follows:
1. The patient has to have a
psychiatric problem
2. PSL must find a facility and
provider there that will
accept them
3. The risks/benefits of transfer
must be explained to the
patient
4. Report must be called to
accepting facility
5. Appropriate level of
transport must be arranged
by sending facility (fill out
PCS form). NOTE: Call 8-LINK
6. Vital signs must be obtained
and documented 15-30
minutes prior to transfer to
show that patient is stable
7. EMTALA transfer form must
be printed out and signed by
attending MD.
8. A copy of chart , to include
labs, notes and CDs with any
films must accompany the
patient along with the
ORIGINAL M1 and Patient
Rights
9. Give signed EMTALA form to
charge nurse to review
NOTE: patient on M1 hold
need not sign the form due
to psych diagnosis
10. Make 2 copies of form (one
for medical records, on e for
EMTALA folder)
11. Obtain face sheet and PCS
form for EMS transporters
12. Make sure your patients
belongings are obtained
from security and go to the
facility with them!

Security Watches in the ED:
Amanda Puhal

Initial Evaluation of the agitated or
psychiatric patient
1. Upon ED bed placement all patients
will be evaluated by nursing staff or ED
physician.
a. Determine if the patient requires a
security watch due to agitation, violent
behavior, or if the patient requires a
mental health evaluation
i. If the person is agitated or actively
verbally or physically abusive towards
staff or there is high suspicion of bodily
harm to self or others, patient will be
monitored 1 to 1. Continuous
observation and a direct line of sight will
be required. Refer to Restraint Use
policy on the UCH Intranet
2. Request a security watch by calling
security supervisor at 83362.
Security Watch patient ratios
If the patient is cooperative, deemed
not to be a flight risk, and/or voluntary,
the ED physician or PSL can authorize
the patient be monitored using a
greater than 1:1 security to patient
ratio, but must not exceed 1:4.

Education Committee Newsletter Psychiatric Considerations Winter 2014


A greater than 1:1 patient monitoring
will be accomplished by the officer
patrolling past or posted where
observation can be maintained on all of
the patient rooms.

Documentation will be made by the
officer every 15minutes per the
Restraint Use P&P.

Documentation of other monitoring and
care will be completed by the ED staff
and physicians as dictated by the
Restraint Use:Acute Medical Surgical
(Nonviolent/Nonself-destructive
patients) and Restraint and Seclusion:
Behavioral Management for the violent
Self destructive (Suicidal) Patient policy.