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38 Cards in this Set
- Front
- Back
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In the ER, what in your immediate surroundings should you be aware of?
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potential weapons such as IV poles or things that can be thrown
objects patient can use for self harm give yourself and patient equal access to the door |
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What is the comfort zone for most people?
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hand shaking distance
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What is the comfort zone for paranoid or agitated patients?
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may be 2 to 3 times the usual distance (hand shaking distance)
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What is the best predictor of future violence?
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immediate past, recent or more distant history of violence
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What is the increase in risk of violence during substance dependence or abuse?
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30x the general population
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What is the increase in risk of violence with antisocial personality disorder with comorbid substance abuse or dependence?
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100x the general population
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What is the increase in risk of violence with mental illness?
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9x the general population
esp. paranoid schizophrenia and confused states related to medical problems |
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What are some behavioral predictors of violence?
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angry words
loud language abuse language physical agitation such as making fists, pacing and akathisia |
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What are some techniques to help de-escalate a violent patient in the ER?
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use a calm voice
sit down with the patient maintain adequate physical distance of at least 6 ft attempt to establish rapport listen to the patient concerns |
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What are the next steps when verbal de-escalation is not enough in the ER?
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when there is a risk of imminent harm and verbal de-escalation has been ineffective either pharmacologic supports or physical restrains may be needed - remember you have all day
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How many trained staff may be needed to physically lay hands on the patient?
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5
'show of force' |
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What qualifies as sufficient restraint?
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a minimum of 2 points
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What should you do following restraining a patient?
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search for potentially harmful objects such as lighters and knives
perform a brief survey for any physical injuries including head injuries and observe movement in all 4 limbs check the head and eyes including eye movements and pupillary response |
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What is one of the most useful medications in the emergency setting? What class is it? What is its use?
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lorazepam - benzodiazepine
in the first 24 hours agitation is as effectively addressed with lorazepam as antipsychotics even if psychosis is present |
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What is the advantage of lorazepam over diazepam and chlordiazepoxide?
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lorazepam is best benzo to be administered IM
diazepam and chlordiazepoxide have erratic absorption |
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What is the advantage of diazepam over lorazepam?
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PO or IV administration of diazepam is effective and actually has more rapid absorption than PO lorazepam
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What forms is lorazepam available in?
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PO, IM and liquid
a sublingual form is available in Canada |
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What is the primary reason for NOT using a benzodiazapine for support in violent/agitation in the ER?
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sedative hypnotic effects which can be additive with other such agents (ex. alcohol) resulting in excessive sedation and respiratory depression
risk of allergic reaction - although very rare paradoxical reaction and actually become more agitated - 5% of the population |
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What are some IM antipsychotic choices for ER agitation? What is the dosing regimen? What are some cautions?
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Ziprasidone (Geodon) 20 mg IM q4 hours or 10 mg q2 hours not to exceed (NTE) 40 mg/24 hours
Olanzapine (Zyprexa) 5 to 10 mg IM NTE 20 mg/24 hours (caution in the elderly) Haloperidol (Haldol) 1 to 5 mg IM q1 hour NTE 20 to 30 mg/24 hours Droperidol (Inapsine) 2.5 to 5 mg IM/IV - note black box regarding arrhythmias |
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T or F
Long acting depo forms of antipyschotics are not started in the emergency room Why? |
True
arrangements for outpaient follow up are needed to continue them |
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What are some PO antipsychotic choices for ER agitation? What is the dosing agitation?
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Risperidone (Risperdal) 1 to mg po NTE 6 mg/24 hours. Also comes in a rapid melting tab called Risperdal M-tab.
Olanzapine 10 to 20 mg po NTE 20 mg/24 hours. Also come sin a rapid melting tab called Zydis. Haloperidol 1 to 5 mg po q 1 to 2 hours NTE 30 mg/24 hours. |
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What antipsychotic is most likely to cause extrapyramidal symptoms?
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haldol followed by risperidone
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In what population are EPS most likely to occur?
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young males and older women
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What are some usual signs of EPS?
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muscle tightness in limbs
tongue thickness and neck tightness more rarely laryngeal and pharyngeal spasm and a sense of choking |
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What is the treatment for EPS?
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be ready to give O2 if breathing problems develop.
PO, IM, or IV diphenhydramine 50 mg q 4-5 hours. IV form acts very quickly so great to use if pt has IV access already. If not may need to use IM. Im takes about 30 min to improve sx and po takes around 60 min. Benztropine 1 to 2 mg PO or IM a 8-12 hrs. |
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What % of college students have had SI?
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1/3
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What % of people who kill themselves tell their doctors?
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1/3
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What is the rate of suicide in the general population?
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12/100,000
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_______ is the 2nd or 3rd most frequent cause of death in adolescents and young adults.
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suicide
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What are the risk factors for suicide?
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mental illness including mood disorders, pyschotic disorders, borderline personality disroder, anxiety disroders, substance issues
older men (>65) particularly those who have lost a partner caucasian chronic illness and/or intractablep ain hopelessness |
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What time frame does psychitatric hospitalization for major depression carry the highest risk for suicide?
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1 year after d/c
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What is the lifetime suicide risk for major depression or bipolar disorder (hx of hospitalization)?
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10 to 20%
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What is the lifetime suicide risk for persons hospitalized for schizophrenia?
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10%
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What should you look for in assessing suicide risk in the ER?
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current suicide ideation
intent to die plans and details of the plans including efforts to secure means to carry out the plan if applicable recent attempts past attempts hopelessness risk factors |
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What are some non-psychiatric causes of psychosis in the ER?
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medications particularly steroids
head injuries metabolic abnormalities infection, particularly those involving the CNS ampthetamines Cocaine PCP LSD |
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What should you do with an affective disorder presenting to the ER?
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typically do not start antidepressant or mood stabilizer because the require close monitoring and take several weeks to become effective
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If a patient blood alcohol level is 200+ and they are alert and clearly conversing, what is likely?
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abuse/dependence
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What test should you do in the ER?
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urinary tox
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