Chapter 145: Psychiatric Emergencies

High-Yield Facts

• In all cases of psychiatric emergencies, organic disease etiology must be ruled out!

• The majority of adolescents are relieved to discuss psychiatric issues and actively seek treatment.

• It is essential to introduce community resources such as crisis lines, substance abuse resources, and centers to patients and families.

• Suicide is common in adolescents: 20% to 25% of American adolescents have considered suicide seriously, 9% have attempted, and it is the third leading cause of death in 15- to 24-year olds and fifth in 5- to 14-year olds.

• Suicide National Hotline: 1-800-suicide.

• Schizophrenia tends to run in families.

• Conversion/somatization disorder is characterized by the presence of apparent physical disease that cannot be delineated organically and has pathologic origination in the psyche, which may present as abdominal pain, respiratory difficulty (paradoxical vocal cord dysfunction), pseudoseizures, and other somatoform disorders.

In 1999 the National Institute of Mental Health estimated that 10% of children have mental illness.¹ By all estimates the number of children with significant psychiatric emergencies presenting to the emergency department (ED) continues to rise and requires significant resources. The first priority in evaluating and treating psychiatric patients in the ED is to determine the risk the patients pose to themselves and others. This assessment guides how best to care for the patient. Safe rooms that have no equipment and are highly visible to staff are optimal for psychiatric patients. Some patients may need one-on-one supervision by staff, others may need restraint.

Table 145-1 lists the historical information that should be obtained from a patient with psychiatric issues presenting to the ED. Emphasis should be placed on past psychiatric history with current medications taken, and a thorough social history to assess the home living condition, family and school relationship problems, and any history of substance abuse. It is important to ascertain the patient's use of social networking (Facebook, etc.) as this can comprise a whole layer of social stressors. After collecting the history from the patient and parent in the examining room together, it is also vital to collect history from parents alone as well as from the child in the absence of the parents.

Examination of the psychiatric patient includes a full physical examination as well as complete neuro and mental status examination. The elements of a mental status examination are reviewed in Table 145-2. Attention should be paid to the caretakers as well as the patient. Assessment of the mental status of the caretaker can reveal much about the ...