Medical Evaluationof Behavioral Emergencies
Lawrence H. Cresswell III
Dustin M. Riccio
John B. McCabe
Patients manifesting abnormal behavior are common in the emergency department (ED). Among these patients, those with acute psychiatric complaints account for 2% to 12% of ED visits in the United States (1, 2, 3). Emergency physicians often perceive encounters with psychiatric patients to be difficult, frustrating, and time-consuming. This may be caused by the need to prioritize care for other patients with acute medical or surgical conditions, by a suboptimal environment in the ED for interviewing patients with psychiatric emergencies, and by discomfort in dealing with such patients. Past studies have indicated a significant incidence of coexisting medical conditions in patients who present to the ED with acute behavioral disturbance (4,5). Coexisting medical illness can often go unrecognized in this patient population and can lead to subsequent morbidity and mortality (6,7). Consequently, it is imperative that patients presenting to the ED with acute behavioral or psychiatric complaints receive full medical evaluation prior to disposition to inpatient or outpatient psychiatric treatment.
The first priority in the evaluation of the patient with behavioral or psychiatric complaints is to identify and correct immediate life threats to both the patient and others. The next goal is to provide medical clearance for the patient. This involves determination of whether the patient’s presenting complaint is functional or organic, whether psychiatric evaluation is required, and whether psychiatric admission is indicated. Underlying medical or surgical illness that could explain the patient’s symptoms or complicate inpatient or outpatient psychiatric treatment should be identified and stabilized as needed. Such medical clearance by the emergency physician can generally be provided through a thorough history, complete physical examination, and selected ancillary and laboratory testing. Emergency physicians are often uncomfortable with medical clearance, because relatively little time is spent during residency training on the evaluation and management of patients with behavioral and psychiatric complaints. This can lead to a suboptimal evaluation of these patients.
For the psychiatrist, medical disease as a cause of psychiatric symptoms should be identified and evaluated prior to the acceptance of a patient for inpatient treatment. The patient who has a primary psychiatric disorder but who has a coexisting serious and unstable medical condition must be differentiated from the patient with stable chronic medical disease and primary psychiatric symptoms. Previous studies have documented the high percentage of patients admitted to state mental health systems with psychiatric complaints who, with thorough medical evaluation, are shown to have significant physical disease (8).
The goals of this chapter are to define psychiatric or behavioral emergency, to describe key components of the medical evaluation for the patient presenting to the ED with acute behavioral or psychiatric complaints, to identify groups that warrant special consideration, to review the differential diagnosis of acute medical and surgical disorders that may masquerade or complicate the evaluation and management of such patients, and to present suggested screening guidelines for the evaluation of such patients in the ED.
PSYCHIATRIC EMERGENCY
The American Psychiatric Association, in 2002, defined psychiatric or behavioral emergency as “an acute disturbance of thought, mood, behavior or social relationship that requires an immediate intervention as defined by the patient, family or
the community” (6). The emergency physician, when presented with such a patient, has the duty to provide medical clearance prior to inpatient psychiatric treatment or discharge to the outpatient setting. The duty is to determine whether a psychiatric emergency exists, to identify potential medical and toxic causes of psychiatric symptoms, and to determine whether these psychiatric symptoms are caused by organic or functional medical conditions.
the community” (6). The emergency physician, when presented with such a patient, has the duty to provide medical clearance prior to inpatient psychiatric treatment or discharge to the outpatient setting. The duty is to determine whether a psychiatric emergency exists, to identify potential medical and toxic causes of psychiatric symptoms, and to determine whether these psychiatric symptoms are caused by organic or functional medical conditions.
MEDICAL CLEARANCE
The phrase medical clearance has been defined many ways and is associated with much controversy. Gregory et al. (9) stated that “patients who have received a medical examination are not necessarily free of all medical illness.” For this reason, the term medical screening was proposed as an alternative.
Weissberg (10) described three separate situations in which the term medically cleared is often used when examining psychiatric patients. The first is when no physical illness is found in the patient with psychiatric complaints. The second is when a patient is known to have a coexisting medical or surgical condition, but this condition is not thought to be the primary cause of a patient’s current acute behavioral emergency. The third is when the patient’s medical condition is identified and stabilized and no longer requires treatment, and therefore the patient is “free” or “clear” to be transferred to the primary care of the psychiatric service.
The American College of Emergency Physi-cians Clinical Policies Subcommittee reviewed problems associated with the use of the phrase medical clearance and concluded that there remains variability, inconsistency, and lack of a standard process both for performing medical evaluations and for declaring psychiatric patients to be “medically clear” (1). Use of the term medical clearance may imply one thing to the psychiatrist and another to the emergency physician. The emergency physician may indicate that there is no acute medical condition that requires further stabilization or management, and no acute medical or surgical condition that explains the patient’s abnormal behavior. The psychiatrist may interpret this to mean the complete absence of significant comorbid medical or surgical conditions. It has been recommended that the statement “medically cleared” be replaced by a detailed evaluation and discharge note from the emergency physician (11). Such concern highlights the need for clear-cut goals for medical evaluation for the patient with acute behavioral or psychiatric emergency.
GOALS OF EVALUATION
Goals of medical evaluation include the following:
Identification of possible medical or surgical causes of acute behavioral change
Differentiation between organic and functional disease
Evaluation, management, and stabilization of significant comorbid conditions
The initial approach to the patient in the ED, even before medical clearance, is to identify and treat potential life-threatening conditions. Such conditions are similar in both the psychiatric and nonpsychiatric patient, and usually are identified and addressed in the first few minutes of patient evaluation. Causes for such life threats are identified in Table 5.1. It is also important to ensure the safety of both the patient and ED staff if the patient is exhibiting violent behavior or has expressed suicidal thought.
TABLE 5.1 Life Threats Requiring Immediate Recognition and Management | ||||||||
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Recent medical literature has reported that approximately 50% of psychiatric inpatients have a serious comorbid medical condition (12). Many of these serious comorbid medical conditions require immediate intervention, whereas others may be the cause of the underlying behavioral change. Although a comorbid medical condition may not need urgent intervention, it may be important to identify during the initial evaluation so that ongoing management plans can be developed. Common
comorbid medical conditions encountered during psychiatric medical evaluations are substance abuse (alcohol and illicit or prescription drugs), hypertension, and diabetes mellitus. The initial evaluation should include a systematic search for diseases that would put other patients and staff at risk. Careful evaluation for infectious diseases such as tuberculosis is important in the initial evaluation.
comorbid medical conditions encountered during psychiatric medical evaluations are substance abuse (alcohol and illicit or prescription drugs), hypertension, and diabetes mellitus. The initial evaluation should include a systematic search for diseases that would put other patients and staff at risk. Careful evaluation for infectious diseases such as tuberculosis is important in the initial evaluation.
It is critical in the process of medical clearance to distinguish functional disease from organic disease. Functional symptoms or conditions are those in which no associated organic or pathologic tissue change can be found by the investigating physician. Functional comorbidities include chronic fatigue, headaches, irritability, and many underlying psychiatric disorders. Organic disease is a term used to describe conditions that are accompanied by physical, cellular, or metabolic changes that can be identified by diagnostic testing. Many organic diseases can masquerade as acute behavioral or psychiatric disorders, including dementia, traumatic brain injury, cerebrovascular disease, cancer, neuroendocrine abnormalities, delirium, and encephalopathy (9).
When evaluating for functional versus organic causes, the age of the patient, time course of symptoms, level of consciousness, medical history, current emotional state, and current vital signs should be taken into account (Table 5.2). Patients with rapid-onset symptoms (within hours), a fluctuating course, disorientation, no previous psychiatric history, and abnormal vital signs generally have an organic cause. Patients with gradual onset of symptoms, a scattered thought process, and past psychiatric history (especially with auditory hallucinations) can be reliably deemed to have a functional cause (13). Using such a quick initial method will aid the clinician in determining effective diagnostic and evaluation strategies.
TABLE 5.2 Differentiation Between Organic and Functional Causes of Acute Behavioral Symptoms | |||||||||||||||||||||||||||
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It is often useful early on to identify and quantify the contribution of drug and alcohol intoxication in the patient’s initial presenting symptoms. Acute intoxicated states as well as withdrawal states can cause altered behavior and psychiatric symptoms. Alcohol psychosis can present with symptoms of hallucination (both auditory and visual) that can be difficult to differentiate from schizophrenia. Alcohol intoxication may also exacerbate existing underlying psychiatric illness. The patient presenting with non-alcohol-related drug intoxications (including cocaine or amphetamines) can also present with altered behavioral state. Careful history and physical exam can identify important clues that will distinguish intoxication-related acute psychosis. The prudent physician evaluating a patient for psychiatric medical clearance must be cognizant of the potential coexistence of alcohol or drug intoxication. Acute or chronic intoxication can exacerbate other medical conditions that may present as existing complicated comorbidities. Examples include aspiration pneumonia with associated hypoxia, nutritional deficiencies, and hypoglycemia.
COMPONENTS OF MEDICAL EVALUATION
History
As with most patients who present to the ED with undifferentiated disease, history is the most important aspect of medical evaluation for patients presenting with acute behavioral or psychiatric symptoms. The history may also be one of the most difficult aspects of the medical evaluation in such patients. Patients with acute psychiatric symptoms may be unable or unwilling to discuss details of their medical condition. Reasons cited in previous literature for the cause of such unwillingness include mistrust of medical staff, confusion, cognitive impairments, and inability to properly voice concerns (14). Patients may also present with altered levels of consciousness or overtly violent behavior. Ensuring the safety of the patient as well as the medical staff during the initial evaluation is of utmost importance. To improve the chances of obtaining appropriate and reliable history, the evaluating physician must appear calm, nonthreatening, and nonjudgmental in such stressful situations. Additionally, it is important for the emergency physician or other examining physician to utilize collateral sources of information, including previous medical records, witnesses to unusual behavior, family, close friends, police, and emergency medical services personnel.
A key question to focus on during the history is the timing or onset of symptoms. It is important to determine whether the event that has brought the patient to the ED is an acute or chronic condition.If the event is acute, what changed or led to the current acute behavioral abnormalities? The question “Why now?” is an all-encompassing question that should be asked, and may yield useful information (14). It is important to establish, early on, a baseline or history of previous psychiatric or behavioral illness, such as history of depression, mania, schizophrenia, or anxiety. It is important to ask directly if there is a history of recent or remote substance abuse, including alcohol. Careful and detailed attention to medications that the patient is currently taking (prescription, over-the-counter, and herbal medication) should be paid. Recent changes in medications or medication doses should be elicited. The patient should be immediately assessed for potential suicidal or homicidal ideation, associated suicidal or homicidal plans, and previous suicidal attempts. A complete past medical and surgical history should be obtained directly from the patient, supplemented by review of prior medical records.
The pediatric patient presenting with abnormal behavior may pose a unique challenge to the examining physician. Children often answer questions that they do not fully understand (14). This may lead the physician to act on inappropriate information. It is especially prudent for the evaluating physician to explore in detail the patient’s past medical and psychiatric history, utilizing all available collateral sources of information.
Physical Examination
Previous studies have documented inadequate or absent physical examination of many patients presenting with acute behavioral or psychiatric disturbance. Studies have shown that as few as one third of psychiatrists routinely examine their inpatients (15). Multiple reasons have been cited for psychiatrists not performing examination, including lack of perceived confidence, desire to avoid transference or countertransference, and dislike of performing medical examinations (14). These studies highlight the need for appropriate and complete physical examinations to be performed, and highlight the need for a generalized approach to physical examinations in such patients.
The physical examination is designed to identify life-threatening abnormalities (see Table 5.1), to identify abnormal physiologic status secondary to organic disease or comorbidities, and to uncover potential explanations for acute behavioral symptoms. When performing the physical exam, a general head-to-toe approach should be used. One must be mindful of the medical and surgical conditions that can present with acute behavioral or psychiatric symptoms, and to actively look for these signs and symptoms.
GENERAL APPEARANCE
General appearance, including a quick look at the patient’s state of alertness, cleanliness, and appropriateness of dress, may give clues to toxic ingestion. Smells and odors associated with intoxicants or metabolic disease (e.g., alcohol, ketones associated
with diabetic ketoacidosis) may be important clues to organic disease. A general assessment of the patient’s level of motor activity, violence, or verbal abusiveness and pressured speech may be important.
with diabetic ketoacidosis) may be important clues to organic disease. A general assessment of the patient’s level of motor activity, violence, or verbal abusiveness and pressured speech may be important.
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