2. 8th leading cause of death for all ages
3rd leading cause of death in adolescents
In the past 20 years suicide killed more
people than HIV and AIDS
90% of patients who commit suicide suffer
from a diagnosable mental illness
About 40-60% of those who die by suicide
are intoxicated at the time of death
10% of patients who attempt suicide will re
attempt within one year
3. Current suicidal ideation
Intent/ Plan
Hx of Suicide Attempts
◦ Date, circumstances, and method
Hx of Mental illness
◦ Intensity of current depressive symptoms
◦ Current treatment
◦ Psychotic Symptoms
Auditory command hallucinations, external control, and religious pre
occupation
Drug and alcohol use
Concurrent medical illness
Past or Present hx of Violence/Aggression
Recent life stressors
Current living situation
4. Make sure patient is fully undressed prior to
entering room
Patients belonging should be taken and stored
He/She should be checked for any pills, drugs,
weapons, sharp objects ect.
Observe patient from doorway or discuss with
nursing interaction, ensure that patient is not
threatening
Pt should have sitter at bedside if he/she has
active SI complaint or are a danger to themselves
5. Only 13% of surveyed psychiatrists perform a physical
exam on their inpatients
Inspect head for trauma or prior neurosurgery
◦ Signs of basilar skull fracture
Ocular exam
◦ Pinpoint pupils – narcotics, organophosphates or clonidine
◦ Dilated pupils – stimulant or anticholinergics, withdrawal from
sedatives, narcotics or post anoxic injury
◦ EOMS- impairment seen with Wernicke’s encephalopathy or space
occupying lesions
◦ Nystagmus-
Vertical (brain stem lesion), Wernicke’s encephalopathy or congenital
Horizontal or rotatory nystagmus suggests drug or more commonly
alcohol toxicity
PCP intoxication – blank open eye stair with roving gas, nystagmus and
dilated pupils
6. Neck exam- meningeal signs or thyroid
enlargement
Chest exam – auscultate for PNA, PTX, CHF,
COPD, Heart Murmur – valvular heart disease
(endocarditis)
Abdominal exam – obstruction, perforation,
hemorrhage, or infection in the abdominal cavity,
enlarged liver (jaundice or asterixis)
Inspect skin for rashes, Kaposi sarcoma or
petechiae, Track marks
Neuro exam is most frequent deficiency in
charts, perform basic neuro exam depending on
suspicion of medical diagnosis
7. Fever in combination with psychiatric
complaint is concerning for intracranial
infection of systemic illness
Hypoglycemia and hypoxia are common
causes of agitation and AMS
8. Hypoglycemia may be responsible for up to
10% of altered behavior in ED patients
UDS is unlikely to change managements,
patients typically will admit to drug or etoh
use if being seen for a psychiatric complaint
Labs including blood chemistries, CBC, UA,
toxicology and alcohol have only a 20%
sensitivity of detecting a medical disorder
History alone has 95% sensitivity
9. CXR – unnecessary in most patients unless hx
of cough, tachypnea or low pulse ox, more
liberal use in the elderly
CT Head – worrisome headache, focal neuro
exam, at risk for chronic subdural (dialysis,
anticoagulated, alcoholic, seizures, falls)
LP – Patients with fever, meningismus or
immunocompromised
10. Points
•Sex
•Age (<19 or > 45)
•Depression or Hopelessness
•Previous suicide attempts or psychiatric care
•Excessive alcohol or drug use
•Rational thinking loss
•Separated, divorced or widowed
•Organized or serious attempt
•No Social Supports
•Stated future intent
Score 6-8: Full Emergency Psychiatric Eval/Treatment
Score 9 or greater: Immediate Psychiatric Hospitalization
1
1
2
1
1
2
1
2
1
2
11. Compliance with psychiatric medications
Social Support
Involvement in a religious group
Being a parent
Positive coping skills
Adequate treatment of chronic pain or
substance abuse
Adequate followup
12. Patient and Complaint Dependent
Attempted Suicide
◦ CBC, BMP
◦ Etoh, UDS, APAP, Salicylate level
◦ EKG
◦ Preg
At a minimum
◦ Most will require Istat8, UDS, etoh, preg
13. PERS- Consult for voluntary admissions, ED
Consults
CSB- Social Worker who will find placement
for ECO/TDO patients
ECO- Emergency Custody Order
TDO- Temporary Detention Order
◦ Medical- Patients who are deemed not able to
refuse treatment or lab work because of medical
condition
14. 4% of the time a medical diagnosis is missed
Deficiencies in history and physical examination accounted
for the vast majority of illness
Most common are infection, pulmonary, thyroid, diabetic,
hematopoietic, hepatic and CNS disease
Hypoglycemia, Hypoxia and Thyroid disease should be
considered in all patients with new onset psychiatric
disease
Serum Sodium > 160 mEq/L is associated with AMS
Serum Sodium < 115 mEq/L produces confusion, coma
and even seizures
Hypercalcemia < 14 mg/dl can cause lethargy and mental
status change
◦ Malignant neoplasms and hyperparathyroidism account for the
vast majority of hypercalcemia
15. Disturbance of consciousness occurring over a
short time and affecting attention, with
impairment in other cognitive function
May be disoriented to time or place but not to
person
Perceptual disturbances including
misinterpretations, illusions or hallucinations
Disturbances develop abruptly and fluctuate
Drug toxicity or withdrawal accounts for up to
30% of all cases of delirium
UTI is one of the most common causes of
delirium in the elderly
16. Effective loss of reality testing, a disturbance
of thought processes and consequently,
changes in behavior
Disrupts perception and disorganizes
thinking to a degree that interferes with
social interactions
Suspect medial etiology in new cases of
psychosis, especially if patient in > 40 y.o
17. Major depression diagnosis requires
alterations in mood, psychomotor activity,
and cognition
15% of patients with major depression
commit suicide
18. Persistently elevated, expansive or irritable
mood
At least three of the following: inflated self
esteem or grandiosity, decreased need for
sleep, increased talkativeness, flight of ideas,
easy distractibility, increased activity or an
excessive quest for pleasure
Mood disturbance is severe enough to
markedly interfere with job performance and
personal relations
19. Complaints of anxiety, nervousness, panic or
stress
Sleep disturbance, irritability, difficulty
concentration, easy fatigue, restlessness, and
muscle tension
If a patient has a panic attack after age 35
and there is no clear cut psychologic
precipitant, suspect a medical cause,
hyperthyroidism, hypoxia, hypoglycemia, or
drug toxicity.
20. Sensation of bugs crawling under skin-
associated with cocaine or speed use
Bugs on the walls – alcohol withdrawal
Visual Hallucinations are strongly associated with
a medical pathology
Seizure prior to presentation suggests postictal
sate or nonconvulsive status epilepticus
Palpitations, tremor and weight loss suggests
hyperthyroidism
Headache suggests CNS tumor, meningitis or
chronic subdural hematoma
21. Late age (over 40) of onset of a new behavioral
symptom
No past medical history of psychiatric illness
Sudden onset of altered behavior
Presence of a toxidrome
Visual Hallucinations
Known systemic disease with new onset behavior
change
New Medication
Altered behavior temporally related to a convulsive
seizure
Abnormal vitals
Disorientation
Clouded consciousness
22. Very Uncooperative patient
◦ 5 MG IM Haldol + 2 MG IM Ativan + 50 MG IM
Benadryl, one syringe
◦ OR 10mg Geodon IM
Somewhat cooperative
◦ PO dosing of above Rx
23. Acute behavior changes in elderly are at risk
for adverse outcomes
Common sequela to infection or other
disease
Nearly 20% of elderly patients brought for
emergency psychiatric eval may be suffering
from a drug reaction
◦ Review BEERS Criteria
http://chpw.org/resources/Providers/Beers_Criteria.pdf