Clinical policy: Critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department

From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department
Annals of emergency medicine (Impact Factor: 4.33). 02/2006; 47(1):79-99. DOI: 10.1016/j.annemergmed.2005.10.002
Source: PubMed
  • [Show abstract] [Hide abstract]
    ABSTRACT: Mental illness is a growing, and largely unaddressed, problem for the population and for emergency department (ED) patients in particular. Extensive literature outlines sex and gender differences in mental illness’ epidemiology and risk and protective factors. Few studies, however, examined sex and gender differences in screening, diagnosis, and management of mental illness in the ED setting. Our consensus group used the nominal group technique to outline major gaps in knowledge and research priorities for these areas, including the influence of violence and other risk factors on the course of mental illness for ED patients. Our consensus group urges the pursuit of this research in general and conscious use of a gender lens when conducting, analyzing, and authoring future ED-based investigations of mental illness.
    Academic Emergency Medicine 11/2014; DOI:10.1111/acem.12524 · 2.20 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction The incidence of respiratory depression in patients who are chemically sedated in the emergency department (ED) is not well understood. As the drugs used for chemical restraint are respiratory depressants, improving respiratory monitoring practice in the ED may be warranted. The objective of this study is to describe the incidence of respiratory depression in patients chemically sedated for violent behavior and psychomotor agitation in the ED. Methods Adult patients who met eligibility criteria with psychomotor agitation and violent behavior who were chemically sedated were eligible. SpO2 and ETCO2 (end-tidal CO2) was recorded and saved every 5 seconds. Demographic data, history of drug or alcohol abuse, medical and psychiatric history, HR and BP every 5 minutes, any physician intervention for hypoxia or respiratory depression, or adverse events were also recorded. We defined respiratory depression as an ETCO2 of ≥50 mmHg, a change of 10% above or below baseline, or a loss of waveform for ≥15 seconds. Hypoxia was defined as a SpO2 of ≤93% for ≥15 seconds. Results We enrolled 59 patients, and excluded 9 because of ≥35% data loss. Twenty-eight (28/50) patients developed respiratory depression at least once during their chemical restraint (56%, 95% CI 42–69%); the median number of events was 2 (range 1–6). Twenty-one (21/50) patients had at least one hypoxic event during their chemical restraint (42%, 95% CI 29–55%); the median number of events was 2 (range 1–5). Nineteen (19/21) (90%, 95% CI 71–97%) of the patients that developed hypoxia had a corresponding ETCO2 change. Fifteen (15/19) (79%, 95% CI 56–91%) patients who became hypoxic met criteria for respiratory depression before the onset of hypoxia. The sensitivity of ETCO2 to predict the onset of a hypoxic event was 90.48% (95% CI: 68–98%) and specificity 69% (95% CI: 49–84%). Five patients received respiratory interventions from the healthcare team to improve respiration [Airway repositioning: (2), Verbal stimulation: (3)]. Thirty-seven patients had a history of concurrent drug or alcohol abuse and 24 had a concurrent psychiatric history. None of these patients had a major adverse event. Conclusion About half of the patients in this study exhibited respiratory depression. Many of these patients went on to have a hypoxic event, and most of the incidences of hypoxia were preceded by respiratory depression. Few of these events were recognized by their treating physicians.
    The western journal of emergency medicine 07/2014; 15(4):430-7. DOI:10.5811/westjem.2014.2.19102
  • [Show abstract] [Hide abstract]
    ABSTRACT: This study investigates if the routine use of the urine drug screen offers any diagnostic or management benefit in the assessment and treatment of psychiatry patients in a suburban psychiatry emergency service. Data was collected retrospectively from consecutive patients 18 years and above, who presented to a large suburban hospital emergency department and had a urine drug screen ordered in the emergency department. A total of 111 patients, (with mean age of participants being 34.9 years, SD 10.2 years, minimum 18 - maximum 62 years, 62.2% (69/111) were male) met the inclusion criteria. The most common drug group identified was benzodiazepines (59.5%; 66/111), followed by cannabis (40.5%; 45/111). Other drugs were identified at much lower levels, including amphetamines (9.0%; 10/111), opiates (4.5%; 5/111) and methadone (0%; 0/111). For most individuals only one drug was detected (55.9%; 62/111), with equal numbers (18.9%) with either zero or two drugs identified by a urine drug screen. Fewer patients had three drugs on a urine drug screen (5.4%; 6/111) or four (0.9%; 1/111). Qualitative urine drug screens provide limited additional information compared to history taking and has minimal impact on clinical management decisions in a psychiatry emergency service. © The Royal Australian and New Zealand College of Psychiatrists 2015.
    Australasian Psychiatry 02/2015; 23(2). DOI:10.1177/1039856214568213 · 0.56 Impact Factor