Psychiatric Emergencies

Delirium

DEFINITION AND DIAGNOSTIC FEATURES

Disturbance of consciousness with impaired attention
Change in cognition or disturbance of perception
- Not better accounted for by a preexisting, established, or evolving dementia
- Memory impairment (most commonly in recent memory)
- Disorientation to time and place and rarely to self
- Speech and language disturbances (dysarthria, dysnomia, dysgraphia, aphasia)
- Perceptual disturbances, including misinter-pretations, illusions, and hallucinations (most commonly visual)
Acute onset (hours to days) and fluctuating during course of the day
Always attributable to a medical or organic cause: look for evidence in the history, physical examination, or laboratory data to indicate that it is direct physiologic consequence of general medical condition, substance intoxication or withdrawal, use of medication, or toxin exposure

COMMON ASSOCIATED FEATURES

Increased or decreased psychomotor activity (hyperactive vs. hypoactive delirium)
Disorganization of thought process (ranging from mild tangentiality to incoherence)
Emotional disturbances, including fear, anxiety, depression, irritability, anger, euphoria, and apathy
Disturbed sleep-wake cycle, at times completely reversed with exacerbation of symptoms at bedtime (also known as sundowning)
Impaired judgment

PREDISPOSING FACTORS

Advanced age
Dementia (see page 58 for more information)
Depression (see page 65 for more information)
Brain injury
History of alcohol abuse (see page 102 for more information)
History of delirium
Functional status (immobility, history of falls, low level of activity)
Sensory impairment (visual and hearing)
Malnutrition, dehydration
Postoperative state, intensive care unit (ICU) stay
Prolonged sleep deprivation

LIFE-THREATENING CAUSES OF DELIRIUM

“Rule out WHIMPS.”

Withdrawal (from alcohol or benzodiazepines)
Wernicke’s (triad: confusion, ataxia, ophthalmoplegia)
Hypoglycemia
Hypoxia (myocardial infarction [MI], congestive heart failure, anemia, carbon monoxide toxicity)
Hypoperfusion of the central nervous system (CNS)
Hypothermia
Hypertensive encephalopathy
Intracerebral hemorrhage
Infection
Meningitis or encephalitis
Metabolic (renal failure, hepatic failure, diabetic ketoacidosis, electrolyte disturbances, acid-base disturbances, adrenal insufficiency)
Poisons (heavy metals, anticholinergics, overdose, intoxication, drug-drug interactions)
Seizures or status epilepticus

MANAGEMENT: GENERAL PRINCIPLES

Delirium is a reversible condition and should be considered a medical emergency
Treat the underlying medical or organic cause(s)
Address and minimize contributing factors

BEHAVIORAL INTERVENTIONS

Acute interventions (see Agitation page 13 for more details)
Provide orienting environmental cues (clock, calendar, names of care providers posted where patient can see them clearly)
Provide adequate social interaction
Have the patient use eyeglasses and hearing aids appropriately
Mobilize the patient as soon as possible
Ensure adequate intake of nutrition and fluids
Educate and support the patient and his or her caregivers

TABLE 2-1 Selected Causes of Delirium

Central nervous system disorders	Stroke Seizure (postictal, subclinical status epilepticus) Meningitis or encephalitis Head trauma (concussion) Degenerative diseases Epidural or subdural hematoma Neoplasms Hypertensive encephalopathy
Metabolic disorders	Acid-base imbalance Fluid or electrolyte imbalance Hepatic failure (hepatic encephalopathy) Renal failure (uremic encephalopathy) Hypoglycemia Diabetic ketoacidosis Endocrinopathies (thyroid, parathyroid, pituitary, pancreas, adrenal) Anemia
Cardiopulmonary disorders	CHF MI Cardiac arrhythmia Hypotension Hypoxia Respiratory failure Shock Carbon dioxide narcosis
Other or systemic illness	Infection (pneumonia, UTI, sepsis) Neoplasm Hypothermia or hyperthermia Severe trauma Deficiencies (thiamine, nicotinic acid, vitamin B₁₂, folic acid) Sleep deprivation Postoperative states
Ingestion or intoxication	Drugs of abuse
		Alcohol, amphetamines, barbiturates, cannabis, cocaine, hallucinogens, hypnotics, inhalants, mushrooms, opiates, PCP, sedatives
	Medications
		Antiarrhythmics, antiasthmatic agents, anticholinergics, anticonvulsants, antihistamines, antihypertensives (especially beta-blockers and clonidine), antimicrobials, antiparkinsonian agents, benzodiazepines, cimetidine, corticosteroids, disulfiram, immunosuppressive agents, insulin, lithium, MAOIs, muscle relaxants, narcotics (especially meperidine), neuroleptics, ranitidine, salicylates
	Toxins
		Carbon monoxide, heavy metals and other industrial poisons, organophosphates, volatile substances, anticholinesterase
CHF, congestive heart failure; MAOI, monoamine oxidase inhibitor; MI, myocardial infarction; PCP, phencyclidine; UTI, urinary tract infection. Adapted from Petit JR. Handbook of Emergency Psychiatry. Philadelphia: Lippincott Williams & Wilkins; 2004:73-74.

TABLE 2-2 Approach to the Evaluation of Delirium

History

Goal: To determine the underlying medical or organic cause

Gather complete medical and surgical history

Gather full medication history, including recent changes to regimen and OTC drugs

Inquire about alcohol and drug use in patients of all ages

General Medical and Neurologic Examination with special attention to:

General Medical Examination

Vital signs, signs of trauma, liver stigmata (spider angiomas, jaundice, palmar erythema, Dupuytren’s contracture, asterixis, gynecomastia, caput medusae, ascites, ankle edema, testicular atrophy), signs of drug use (track marks, “meth mouth”), nuchal rigidity, evidence of recent seizure activity (tongue or cheek lacerations, bruising), pulmonary congestion, cardiac arrhythmias

Neurologic Examination

Cranial nerves, spontaneous movements, pupil size and reactivity, deep tendon reflexes, signs of increased ICP (headache, vomiting, HTN, low HR, unilateral dilated pupil, papilledema), gait

Psychiatric Mental Status Examination with special attention to:

Appearance and behavior: Hypervigilant, frightened, poor eye contact, agitated, exhibiting psychomotor retardation

Speech: Rambling, incoherent, rapid, fluent

Mood and affect: Depressed, fearful, tearful, irritable, anxious, angry, apathetic, despondent, perplexed, blunted

Thought process and content: Paranoid, loose associations, hallucinations

Cognition: Disorientation, decreased concentration, confusion, impaired memory

Laboratory Studies, Imaging, and Other Diagnostic Tests

Initial basic tests: Electrolytes, glucose, renal function (BUN or creatinine), liver function tests, serum and urine toxicology screens, CBC, ECG, CXR, urinalysis

Additional tests (when indicated): Head imaging, urine culture and sensitivity, vitamin B12 and folate, thyroid function tests, RPR or VDRL, heavy metal screen, ANA, ESR, ammonia level, HIV testing, EEG

ANA, antinuclear antibody; BUN, blood urea nitrogen; CBC, complete blood count; CXR, chest radiography; ECG, electrocardiography; EEG, electroencephalography; ESR, erythrocyte sedimentation rate; HIV, human immunodeficiency virus; HR, heart rate; HTN, hypertension; ICP, intracranial pressure; OTC, over the counter; RPR,= rapid plasma reagin; VDRL, Venereal Disease Research Laboratory test.

PHARMACOLOGIC INTERVENTIONS

If possible, avoid using medications until the underlying cause has been determined
Use lower doses for elderly patients and persons with parkinsonism, traumatic brain injury (TBI), and mental retardation
First-line medications are typical or atypical antipsychotics (see Agitation page 13 for more details)
- Begin with a single antipsychotic and titrate the dose to symptom response
- Bedtime or twice-daily (BID) dosing on an as-needed (PRN) basis is often helpful
Avoid benzodiazepines and anticholinergics
- They may increase confusion or paradoxically increase disinhibition
- Watch for respiratory depression and oversedation
- Benzodiazepines are associated with prolongation and worsening of delirium symptoms
Consider nonbenzodiazepine anxiolytics (see Agitation page 13 for more details)

PHYSICAL RESTRAINTS

Used when less restrictive measures have failed or when the patient exhibits severe agitation or violent behavior (see Agitation page 13 for more details)

Agitation

DEFINITION

Agitation: a state of poorly organized and aimless psychomotor activity that stems from physical or emotional unease
Signs and symptoms: motor restlessness, hyperactivity, irritability, decreased attention, increased distractibility, increased reactivity, increased mood lability, uncooperative or inappropriate behaviors, decreased sleep
Psychological correlates: fear, anger, anxiety, pain or discomfort
Agitation is a symptom that may occur in a variety of psychiatric disorders
Compare with aggression: overt behavior involving an intent to inflict noxious stimulation on or to behave destructively toward another organism
- May be impulsive or premeditated
- Most often not primarily caused by a psychiatric etiology

SELECTED CAUSES OF AGITATION

Delirium
Psychosis
Mania
Anxiety or depression
Dementia
Intoxication or withdrawal
Medication side effects

Figure 2-1 Management of agitation.

NONPHARMACOLOGIC MANAGEMENT

General Principles

Agitation is a behavioral emergency
Maintain patient and staff safety
Maximize patient comfort
Screen for and treat medical abnormalities
Treat drug intoxication and withdrawal
Treat psychiatric symptoms (e.g., anxiety, psychosis)
Use tranquilizing medications if needed

Behavioral and Verbal Interventions

Use good eye contact (avoid staring; watch facial expressions)
Watch the person’s interpersonal space (distance, altitude, movement)
Use good posture (relaxed, open handed, equal egress, 90 degree)
Don’t touch!
Be empathic to the patient’s condition and problems
Accept what the patient says (don’t challenge)
Anticipate shame, vulnerability, and loss of self-esteem
Express concern and desire to protect the patient from harm
Acknowledge the patient’s power to make decisions but be firm about boundaries and limits
Use distractions (food, drink, blanket, magazine, phone call)
Report to patient what you observe (“you are scaring me”)

Environmental Interventions

Remove all potentially dangerous objects
Isolate (decrease interpersonal stimulation)
Decrease external stimuli (quiet room, individual examination room)
Use a show of force (security)
Provide one to one observation

Seclusion and Restraints

These are required when patients are at substantial risk of harming themselves or others and when less restrictive measures have failed
Always use the least restrictive means possible. Try alternative measures first. Behavioral or verbal and environmental interventions as above; as needed medications and pharmacologic management
Implement for the least amount of time possible, as mandated by the clinical situation
Know your specific state-mandated protocol for initial assessment and reevaluation of restrained patients
Consider criteria for release (e.g., “able to engage in mutual dialogue with staff, noncombative”). Sleeping should be a criterion for release EXCEPT when it is thought that releasing the patient would lead to further agitation
Morbidity associated with physical restraints: fractures, abrasions, bruises, aspiration pneumonia, deep vein thrombosis (DVT) and pulmonary embolism, decubitus ulcers (from prolonged immobilization)

PHARMACOLOGIC MANAGEMENT

General Principles

Offer the patient as needed medications
Try to use any sedating or antipsychotic medications the patient is currently taking
The mainstay of treatment is use of typical and atypical antipsychotics; combine them with sedating medications or anticholinergic medications if indicated
If the patient is unwilling to take medications by mouth or if a faster onset is required, use the intramuscular (IM) route (or the intravenous [IV] route if available)
Titrate dose to symptom response
Routes of administration (how long to take effect)
- Orally (PO): takes effect in 20-30 min; maximum effect in 1 hr
- IM: takes effect in 10-15 min; maximum effect in 30 min
- IV: takes effect in few minutes
Special populations: elderly patients, children, medically compromised patients
- Start low, go slow
- Avoid anticholinergic agents (risk of delirium)
Give low-dose benzodiazepines only (may paradoxically increase disinhibition)
Consider atypical antipsychotics (especially risperidone and olanzapine) in geriatric patients with dementia and agitation

TABLE 2-3 Typical Antipsychotics

Drug	Dose Range	PO	IM	IV	Considerations for Use in Acute Agitation
Haloperidol (Haldol)	5-10 mg	X	X	X	High-potency D2 receptor blockade: high antipsychotic, anti-agitation effect Minimally anticholinergic or sedating: typically used in combination with anticholinergics and BZD for sedation High EPS risk when given alone (especially in young, muscular men) IV route has fewer side effects but requires monitoring of QTc
Chlorpromazine (Thorazine)	25-200 mg	X	X		Medium potency at dopamine receptors Highly anticholinergic and sedating; do not need to give in combination with anticholinergics or BZD Low EPS risk Watch for postural hypotension Do not use in geriatric patients
Perphenazine (Trilafon)	4-20 mg	X	X		Can replace haloperidol in combination treatment Medium potency at dopamine receptors Medium anticholinergic side effects Medium EPS risk
BZD, benzodiazepine; EPS, extrapyramidal side effects; IM, intramuscular; IV, intravenous; PO, orally.

Figure 2-2 Classic combination treatment. EPS, extrapyramidal side effects.

Atypical Antipsychotics

In general, there is a lower risk of extrapyramidal side effects (EPS) than with typical antipsychotics, but EPS may still occur
When using IM olanzapine, avoid coadministration with other medications, especially benzodiazepines or other CNS depressants as there have been eight case reports of sudden death, cardiovascular complications, and respiratory depression

Adjunctive Medications

Anticholinergics: use with high-potency neuroleptics (haloperidol) to prevent EPS
- This is especially important in young males and patients with previous dystonic reactions
- Watchfordeliriumwhenusing inelderly,mentally retarded,or TBIpatients
Benzodiazepines: use for anxiety symptoms, withdrawal, sedation, akathisia
- Watch for delirium and paradoxically increased disinhibition when using in elderly, mentally retarded, or traumatic brain injury patients
Nonbenzodiazepine anxiolytics: use for anxiety symptoms in patients in whom benzodiazepines are risky

TABLE 2-4 Atypical Antipsychotics

Drug	Dose Range	PO	IM	SL	Considerations for Use in Acute Agitation
Olanzapine (Zyprexa, Zyprexa zydis)	2.5-20 mg	X	X	X	Low EPS risk Significant anticholinergic effects
Quetiapine (Seroquel)	12.5-200 mg	X			Low EPS risk Watch for postural hypotension, sedation, headache
Risperidone (Risperdal)	0.5-2 mg	X			EPS risk is comparable to typical antipsychotics at higher doses (>8 mg) Watch for postural hypotension, headache, nausea or vomiting, rhinitis, cough
Ziprasidone (Geodon)	10-20 mg	X	X		Low EPS risk Watch for sedation, nausea, dizziness Reports of anxiety and agitation (activation) resembling akathisia but may resolve spontaneously over time
Aripiprazole (Abilify, Abilify Discmelt)	2-10 mg	X		X	Low EPS risk Watch for postural hypotension, akathisia
Aripiprazole (Abilify, Abilify Discmelt)	5.25-15 mg		X		Low EPS risk Watch for postural hypotension, akathisia
BZD, benzodiazepine; EPS, extrapyramidal side effects; IM, intramuscular; LFT, liver function test; PO, orally; SL, sublingual.

SIDE EFFECTS AND MANAGEMENT

Extrapyramidal Symptoms: General Principles

Higher frequency of EPS with typical antipsychotics
Includes acute dystonia, akathisia, parkinsonian-like effects

Acute Dystonia

Acute muscular rigidity and cramping
Most likely occurs within the first week of neuroleptic initiation
Particularly common after IM haloperidol
Risk factors: young men, history of dystonic reaction
Very uncomfortable and frightening for patients
Watch for laryngeal dystonia, which includes airway compromise and is a medical emergency
Treat with benztropine, diphenhydramine, or lorazepam
If an antipsychotic is being continued, maintain the anticholinergic for 2 weeks (benztropine 2 mg BID for 14 days)

TABLE 2-5 Adjunctive Medications

Class	Drug Name	Dose Range	PO	SL	IM	IV	Considerations
Anticholinergics	Diphenhydramine	25-50 mg	X		X	X	Use with haloperidol to prevent EPS Watch for delirium
Anticholinergics	Benztropine	0.5-2.0 mg	X		X	X
Benzodiazepines	Diazepam	5-10 mg	X		X	X	RO, LD, active metabolites	Watch for delirium and paradoxically increased disinhibition
	Lorazepam	0.5-1.0 mg	X	X	X	X	RO, SD
	Clonazepam	0.5-1.0 mg	X				SO, LD
	Alprazolam	0.25-0.5 mg	X				RO, SD
	Midazolam	1-2 mg	X			X	RO, SD, potent respiratory depressant
Non-benzodiazepine anxiolytics	Clonidine	0.05-0.1 mg	X				Often used in children hypotension
	Trazodone	25-100 mg	X				Often used in elderly Side effect: priapism
	Gabapentin	100-300 mg	X
	Buspirone	5-20 mg	X
	Zolpidem	5-10 mg	X
	Propanolol	10-20 mg	X				Use in patients with akathisia
EPS, extrapyramidal side effects, IM, intramuscular; IV, intravenous; LD, long duration; PO, orally; RO, rapid onset; SO, slow onset; SD, short duration; SL, sublingual.

Figure 2-3 Treatment for acute dystonia. IM, intramuscular; IV, intravenous.

Akathisia

Feeling of inner restlessness and the need to move, especially the legs
Difficult to distinguish from anxiety and agitation related to psychosis; increased restlessness after initiation of a typical antipsychotic should always raise suspicion for akathisia
Treatment varies by clinical situation

Parkinsonian-like Effects

Symptoms include bradykinesia, rigidity of the limbs, resting tremors, cogwheeling, masked facies, stooped posture, festinating gait, and drooling
Onset of symptoms is usually after several weeks of therapy
Most common in elderly patients who are taking high-potency drugs
Treatment:
- Switch from a typical to an atypical antipsychotic
- Decrease to the lowest effective dose of antipsychotic
- Add a fixed dose of antiparkinson drug (benztropine 1-2 mg BID)

TABLE 2-6 Treatment for Akathisia

Situation	Treatment (Ranked by Preference)
When the patient is treated with high-potency typical antipsychotic drug and does not have other EPS	Propanolol 10-30 mg TID Benztropine 1-2 mg BID Lorazepam 1 mg TID or clonazepam 0.5 mg BID
When the patient is treated with low-potency typical antipsychotic drug or an antipsychotic and a tricyclic antidepressant and does not have other EPS	Propanolol 10-30 mg TID Lorazepam 1 mg TID or clonazepam 0.5 mg BID Benztropine 1 mg BID
When the patient is treated with an antipsychotic and manifests other EPS symptoms (dystonias, parkinsonism)	Benztropine 1 mg BID Benztropine with propanolol 10-30 mg TID Benztropine with lorazepam 1 mg TID or clonazepam 0.5 mg BID
When other EPS are present and akathisia is unresponsive to an anticholinergic alone	Benztropine 1-2 mg BID with propanolol 10-30 mg TID Benztropine 1-2 mg BID with lorazepam 1 mg TID or clonazepam 0.5 mg BID
BID, twice a day; EPS, extrapyramidal side effects; TID, three times a day. Adapted from Rosenbaum JF, Arana GW, Hyman SE, et al. Handbook of Psychiatric Drug Therapy, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005:42-43.

Cardiac Arrhythmias

All antipsychotics have quinidine-like cardiac effects, which increase the risk of cardiac arrhythmias through prolongation of corrected QT interval (QTc)
Obtain a baseline electrocardiogram(ECG) or follow-up ECGin patients with:
- Known elevated QTc
- Family history of sudden death
- Known heart disease
- Known to be taking drugs that prolong QTc interval (e.g., quinolones)
Provide cardiac monitoring at higher doses (watch for QTc prolongation and torsades de pointes)
Replete K and Mg to a high normal range

Neuroleptic Malignant Syndrome (NMS)

(See page 39 for more details)

Anticholinergic Side Effects

Dry mouth
Hyperthermia
Constipation
Urinary retention
Blurred vision
Narrow-angle glaucoma
Memory deficits
Hallucinations
Delirium(see page 9 for more information)

Other Side Effects

Oversedation and respiratory compromise: carefully monitor vital signs
Orthostasis and fall risk; monitor orthostatic blood pressure (BP) and place the patient on fall precautions when appropriate

Catatonia

DIAGNOSTIC FEATURES

At least two of the following five features must be present:

Motoric immobility: with rigidity, including waxy flexibility (e.g., resistance to arm repositioning), catalepsy or with minimal response to stimuli (stupor)
Excessive motor activity: apparently purposeless and not influenced by stimuli (e.g., constant unrest, screaming, taking off clothes, running down hallway)
Extreme mutism: verbal unresponsiveness (e.g., while occasional eye contact) or extreme negativism: motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved (e.g., grinding teeth while the jaw is pulled down, squeezing the eyelids during an eye examination)
Peculiarities of voluntary movement:
- Inappropriate or bizarre posture (e.g., sitting or standing without reaction)
- Stereotyped movement (e.g., repetitive patting or rubbing oneself)
- Prominent mannerism (e.g., walking on tiptoe)
- Grimace (e.g., forceful, odd smile)
Echolalia or echopraxia: repeating the words or movements of the inter-viewer

ETIOLOGIES

Neurologic or medical illness (e.g., toxic-metabolic, infections, CNS diseases, drugs, poisoning)
Psychiatric disorder (e.g., mood disorders, schizophrenia, acute psychosis, conversion disorder)

PRINCIPLES OF MANAGEMENT

Early recognition
Diagnosis and treatment of neuromedical illnesses: obtain a complete blood count (CBC), complete metabolic panel, creatine kinase (often increased), Fe (decreased Fe is a risk factor for catatonia), urinalysis (UA) (consider rhabdomyolysis), urine toxicology, serum toxicology, cultures, consider brain computed tomography or magnetic resonance imaging and electroencephalography
Close observation and frequent vital signs. Consider malignant catatonias (including NMS- see page 39 for more information) with autonomic hyperactivity and fever (associated with a 50% mortality rate if center untreated)
Supportive care: hydration, nutrition, mobilization, anticoagulation, precautions against aspiration
Discontinue antipsychotics or other possible culprits (e.g. metoclopramide)
Restart recently withdrawn dopamine agonists or benzodiazepines
Institute supportive measures: cooling blanket if hyperthermia or parenteral fluids and antihypertensives or pressors
Suspect medical complications

TREATMENT

Treat etiology (see above)
Lorazepam IV, PO, or IM deltoid (first-line agent regardless of cause; 80% effective) 1-2 mg IV initial dose; may repeat q30 min, monitor respiratory rate, up to 20 mg/d (occasionally); switch to PO or nasogastric (NG) 6-20 mg total daily dose for maintenance
Other agents: amantadine 100 mg PO BID; bromocriptine 2.5-5.0 mg PO BID; memantine 5-10 mg PO BID; topiramate 100 mg PO BID
Electroconvulsive therapy (ECT)

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