Psychiatric Emergencies in the Pediatric Emergency Department

1. Psychiatric Emergencies in the Pediatric Emergency Department Michael F. Ziegler, MD Assistant Professor of Pediatrics and Emergency Medicine Emory University/Children’s Healthcare of Atlanta

2. Scope of the Problem • US Dept of Health and Human Services • 1 in 10 children in USA (4 million) suffers from a mental illness • Only 20% will receive needed care • Psychotherapy recommended for < 50% of patients evaluated for suicide attempt in the ED with even fewer actually complying with referral • World Health Organization • By 2020 childhood neuropsychiatric disorders will be 1 of the top 5 causes of morbidity, mortality and disability among youth worldwide

3. Scope of the Problem • Overall ED use increasing, same seen for psychiatric concerns • 1993 to 1999 (Sills and Bland) • 1.6% of all ED visits in the < 19yo age group were for mental health • 326.8 visits/10,000 people/year were psychiatric • 13.6% diagnosed as suicide attempt • 10.8% diagnosed as acute psychosis • Largest increase seen in nonurgent diagnoses (i.e. same as non-psych visits) • Increase felt to be due to decreased availability of mental health providers (actual numbers vs. access) • 1995 to 1999 (Page) • 59% increase in pediatric psychiatric visits to a children’s hospital ED

4. Scope of the Problem • Higher rate of admissions • 1 year study by Khan, et al ‘02 • 227 children with psychiatric illness evaluated • 32% admitted • 60% to medical floors due to lack of facilities for mental health • Longer turn around times to discharge, admission and transfer to floor when compared to non-psych • 19,734 children with non-psychiatric illness evaluated • 5.5% admitted

5. Scope of the Problem • Suicide • 2 million US adolescents attempt suicide each year • 2000 succeed • Third leading cause of death for age 15-24 years • Fourth leading cause of death for age 10-24 years • 19% of US adolescents report serious consideration of suicide in the past year

6. Scope of the Problem • PECARN workgroup • 5 site project to define incidence and character of psychiatric emergency visits to pediatric emergency departments and to develop intervention strategies to address increasing utilization

7. “Psych” vs. “Non-psych” • An artificial distinction based on our lack of knowledge and understanding of psychiatric illness • Seizures used to be a psychiatric diagnosis • Schizophrenia now understood in a physiologic model with increased dopamine levels • Many psychiatric problems are exaggerated responses of normal coping and adaptive functions in the brain/psyche (i.e. PTSD, Panic Attacks, Dissociative Disorders)

8. General Approach • Crisis intervention • Usual coping and adaptive patterns of child and family disrupted • Risk to patient’s health and wellbeing • Risk to patient’s safety • Risk to others • Assessment, treatment and disposition must include the child and the family • Ensure physical and emotional safety of child • Provide support and nurturance • Set limits on behavior

9. The ED environment • Everything should be done in a non-judgmental and caring manner • “Check your own pulse first” • Patients should be searched • Removal of weapons or drugs that might be used to hurt self or others • Clothing should be removed and confiscated • Decreases elopement • Place in a safe and quiet environment • Decrease stimulation • Minimize access to dangerous materials • Chemical or physical restraints as necessary and appropriate

10. Evaluation • Orienting data • Relevant history • Acute vs. sub-acute presentation • Medical history and physical examination • Assess for organic causes • Mental status of the patient • Assess for organic causes • Define specific problem • Family evaluation • Disposition viability

11. Orientation Appearance Memory Acute and remote Cognition concentration Behavior Relating ability Speech Pressured? Affect Thoughts Looseness of associations Flight of ideas Hallucinations Insight and judgment Strengths Synthesis Mental Status Exam

12. Ancillary studies • Not generally necessary if history and physical can exclude organic etiology of symptoms, however, reasonable considerations include:

13. Urine or serum drug screens Assessment of pregnancy in females Chemistries CBC ABG Liver enzymes Thyroid studies LP CT/MRI Blood lead level Ammonia level HIV/RPR ESR/ANA Cortisol EEG Ancillary studies

14. Toxidromes • Sympathomimetics • Tachycardia/HTN/hyperthermia/euphoria/dilated pupils • Opioids • Pinpoint pupils/bradypnea/hypotension • Anticholinergic delirium • “red as a beet, dry as a bone, blind as a bat, and mad as a hatter” • Cholinergic excess • SLUDGE • Extrapyramidal symptoms

15. Required work-up for “medical clearance” • Grady 13b • CBC, BMP, UDS, Urine Beta for females • Peachford Pediatric Psychiatric Hospital • UDS and Urine Beta for females • Rest depends on your judgment

17. Pharmacotherapy • Agitated, violent or psychotic patients • Antihistamines • Benzodiazepines • Neuroleptics • Atypical antipsychotics • Mood stabilizers primarily for bipolar disorder • Lithium • Depakote-better for childhood bipolar • Tegretol-better for childhood bipolar

18. Benzodiazepines • Ativan 0.05-0.1mg/kg/dose • Rapid sedation • No active metabolites • Short half-life • Route: PO/IM/IV/PR/SL • Problems • Respiratory depression • Paradoxical reaction • Worse in developmentally delay or organic brain syndromes

19. Neuroleptics • Antipsychotic effects take 7-10 days, but sedation immediate • Haloperidol • Children: 0.025-0.075mg/kg/dose (max 2.5mg) • >12yo: 2-5mg/dose • Route: PO/IM (IV with caution) • Problems • EPS • Treat with diphenhydramine or benztropine • NMS • Treat with Dantrolene

20. Droperidol • Better sedation than Haldol • “Black box” warning for prolongation of QT interval leading to Torsades de Pointes • Several new studies disputing this point • No strong evidence to support a causal relationship between use of Droperidol and fatal arrhythmias • Dose 0.03-0.07mg/kg/dose (max 2.5mg) • Problems • Orthostatic hypotension • Serotonin syndrome (esp. seen with LSD)

21. Atypical antipsychotics • Lower incidence of EPS • Ziprasidone • No dosage info available for children • Associated with prolonged QT • Olanzapine • Route: ODT/IM • 0.12-0.29mg/kg/dose

22. Combo therapy • Diphenhydramine with Neuroleptics/Atypical antipsychotics • Reduced EPS • Increased sedation • Benzodiazepines with Neuroleptics/Atypical antipsychotics • Increased sedation

23. Inflexible sad mood Anxiety Self-deprecation Loss of functioning Suicidal/homicidal ideation Most important aspect to assess Associated with School problems Chronic illness Genetic predisposition Developmental differences Infancy Childhood Adolescence Depression

24. Suicide • Most acute aspect of psychiatric emergencies • Greatest benefit from intervention • Suicidal tendencies are typically fleeting with increases after stressors, but decrease to zero within several weeks after the acute event in most adolescents

25. Suicide Stats • Rare before puberty, but not non-existent • Age perceptions of death • Attempts more common in females • Ingestions most common method in attempts • Completion more common in males • Firearms most common method in completed attempts • Neighborhood • Rural-firearms • Suburban-carbon monoxide • Urban-jumping from buildings • Suicide attempts via ingestion in age 5-14 years 5 times more common than all forms of meningitis

26. Completed suicides • >90% have a psychiatric condition • Depression and substance abuse • Psychosis (small percentage, but high risk) • Impaired judgment, hallucinations, delusions of persecution • 1/3 have made previous attempts • 1/2 have been ill for over 2 years • Family history of suicide • History of physical or sexual abuse • Gay, lesbian or bisexual sexual orientation

27. AssessmentASK!!! • Frequency of thoughts about suicide • Intensity of these thoughts • Duration of these thoughts • Specificity of plan • Hopelessness • Rapid denial in apparent significance of attempt worrisome Remember that lethality of past attempts is not synonymous with intention!!!

28. Treatment • Psychiatric consultation • Never prescribe antidepressant medications • Encourage family to tell patient they want him or her to live and that suicide is forbidden • Tender, but firm with setting boundaries

29. Inpatient No studies exist that show a reduction in risk of future suicide attempts or completed suicides for patients hospitalized Outpatient Follow up within days “Sanitized” residence Contract for safety No evidence this prevents suicide Disposition

30. Psychosis • Severe disturbance in patient’s mental functioning • Cognition • Perception • World is threatening • Mood • Ecstatic or despondent • Impulses • Reality testing

31. Age at onset • Autism • Onset before 30 months of age • Other developmental disorders • Onset between 30 months – 12 years • Asperger’s syndrome (intelligent autism) • Schizophrenia • Onset in adolescence • Acute reactive psychosis and Bipolar disorder • Onset in late childhood or adolescence

32. Organic vs. Psychiatric

33. Organic causes of psychosis • CNS lesions • Structural and functional • CNS hypoxia • Metabolic disorders • Collagen-vascular disease • SLE • PAN • Infections • Toxins

35. Management • Psychiatric consultation • Admission to medical unit if organic cause suspected • Avoid antipsychotic meds if possible • Use physical restraints if toxin induced psychosis not suspected

36. Schizophrenia • 0.5% prevalence in population • Males = females • Possible excess of Dopamine • Common features • Flat or bizarre affect • Loose associations • Auditory hallucinations • Thoughts spoken aloud • Delusions of external control • Concrete thinking

37. Acute Reactive Psychosis • Time limited loss of reality caused by externally imposed traumatic events • Not a permanent psychiatric disorder • Prognosis depends on ability to reestablish safe and dependable support

38. 0.5% prevalence Adult and Childhood forms Childhood form aka “rapid cycling” Strong family history connection Common features Insomnia Hyperactivity Pressured speech Emotional lability Flight of ldeas Inflated self-esteem Aggressive and combative Reckless behavior Hypersexual Buying sprees Manic-Depressive or Bipolar Disorder

39. Other psychiatric disorders • PTSD • Reexperiencing, avoidance, hyperarousal • Dissociative Disorders • Extreme trauma leads to splitting of integrated functions of identity, memory and consciousness • Includes conversion reactions, fugue states and multiple personality disorders • School refusal • Main goal is restoration of normal function • Do not do excessive labs! • Send them back to school!

40. ADHD • Associated with depression and suicide attempts • Associated with bipolar disorder • Associated with antisocial personality disorder

41. Conduct Disorders • Repetitive, socially unacceptable behavior, without evidence of medical or other psychiatric disorder • Males 5 times more likely to develop than females • High incidence of violence • Usually seen in conjunction with law enforcement • Diagnosis of exclusion

42. Conduct Disorders • Narcissistic • Manipulative • No remorse or guilt • Angry at detection and punishment • Persecution complex • Substance abuse • Sexual promiscuity

43. Assessment and Treatment • Assess for medical or psychiatric illness • Firm control and detailed expectations with assistance of security and restraints when necessary • Parents should be directed to assist with control of behavior in department

44. Antisocial Personality Disorder • Classic triad • Bed wetting • Pyromania • Cruelty to animals • Common to many serial killers

45. Thank you for your time and attention! Now, can someone please get me a change of underwear, a match, some gasoline and a puppy?