Behavioral Emergencies

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					Behavioral Emergencies


          Summer 08
          Strange But True
 A 28-year old male was brought into
the ER after an attempted suicide. The
     man had swallowed several
nitroglycerin pills and a fifth of vodka.
When asked about the bruises about
his head and chest, he said that they
were from him ramming himself into
 the wall in an attempt to make the
       nitroglycerin explode.
         What’s this all about?
   Is it normal or abnormal?
   Prevalence?
   Pathophysiology of behavioral and
    psychiatric disorders
   Factors that alter behavior or emotional
   Medical legal considerations
   Overt behaviors associated with behavioral
    and psychiatric disorders
   Verbal techniques useful in mgmt of the
    emotionally disturbed pt.
   Appropriate safety measures
   When should family, etc be removed from
   Techniques for physical assessment
   When are you expected to transport a
    patient against his/her will?
   To restrain or not?
   Affect                     Bereavement
   Anger                      Biological/organic
   Anxiety                    Bipolar disorder
   Confusion                  Catatonia
   Depression                 Delirium
   Fear                       Delusions
   Mental status              Dementia
   Open-ended questions       Flat affect
   Posture                    Manic
   Post-traumatic stress      Multiple personality
    syndrome                    disorder
   Psychogenic amnesia        Phobia
   Schizophrenia              Positional asphyxia
        Behavioral and Psychiatric
   Not clear cut
   They require a complete history, exam,
    and careful/skilled approach
   Most of what you do will depend on your
    people skills
   Behavioral emergency
       Behavior is so unusual, bizarre, threatening or
        dangerous – possibly life-threatening to self
        or others
     What is normal, anyway???
   Determined by
       Culture
       Ethnic groups
       Socioeconomic class
       Personal interpretation, opinion
   Does it
       Interfere with core life functions?
       Pose a threat to the life or well-being of the patient or
       Significantly deviate from society’s expectations?

   Normal ? Behavior that is readily acceptable in
    a society!
   ~ 20% of population has some type of
    mental health problem
   1 in 7 will require treatment
       Anxiety
       Depression
       Eating disorders
       Mild personality disorders
   Behavioral and psychiatric disorders
    incapacitate more people than all other
    health problems combined!
                True/not true?

   All mental patients are unstable and
   Their conditions are incurable
                Biological causes
   Alcohol

   Drugs (including OTC, Rx)

   Infection

   Tumors
    Potential Organic Causes

Frontal atrophy from   Brain neoplasm
 Alzheimer’s disease

   Personality style
   Dynamics of unresolved conflict
   Crisis management methods
   Environment
       Traumatic childhood incidents

   Situational
       Relationships
       Support systems
       Social isolation
       Rape/assault
       Witnessing acts of violence
       Loss of a job
       Ongoing prejudice or discrimination
Assessment of behavioral patients
   The same as for all other
       Scene size-up – look for
       Initial assessment – watch
        posture & body language
       Focused history
       Physical examination
   You begin your care at the
    same time – good
    interpersonal skills!
              More about the H & E
   Listen – open-ended questions
       Pay attention
   Spend time
   Be assured
   Do not threaten
   Let there be silence
   Place yourself at their level
   Keep a safe & proper distance
   Appear comfortable
   Don’t judge
   Never lie
      Mental status examination
   General appearance
   Behavioral observations – verbal and non-verbal
   Orientation
   Memory
   Sensorium – is pt. focused, paying attention?
   Perceptual processes – thought patterns ordered?
   Mood and affect
   Intelligence
   Thought processes
   Insight
   Judgment
   Psychomotor
Form a general impression
   25 – 50% over 85 y/o have dementia
       Alzheimer’s most common
       Mini-strokes
   Affected person sometimes recognizes
    first signs
       Keys?
       Lost while driving, etc
       Common tasks
       Difficulty with words
   Time between first symptoms & death – 7
    – 10 years
   Gradual impairment of                 Affect
    memory and cognitive                      Normal or flat, depending
                                               on stage of condition
       Forgetfulness
                                          Aphasia
                                              Impaired communication
       Failure to recognize objects
        or stimuli                        Apraxia
                                               Impaired motor activities
   Orientation                            

       Excellent recall of past
                                          Agnosia
        history                               Failure to recognize objects
       May not remember current          Disturbance in executive
        events                             functioning
                                              Impaired ability to plan,
                                               organize or sequence

   Causes:
     Alzheimer’s disease
     AIDS

     Parkinson’s disease

     Vascular disease

     Head trauma

     Substance abuse
    Dementia and Delirium

   Delirium may occur in dementia patients
   Delirium Presentation
       Rapid onset (hours or days)
       Inattention, disorientation, memory
        impairment and visual hallucinations
   Causes of delirium are usually reversible
       Rule out acute medical problems, medication

   Supportive
   Meds
       Aricept
       Cognex
   Gross distortions of reality
   Preoccupation with inner
   Withdrawal from social
   Disorganization of thoughts,
    perceptions, and emotions
   Behavior linked with
    medication noncompliance
   Chronic substance abuse in
    teenage years linked to
    development of the disease
        Schizophrenia Symptoms
   Disorganized behavior/dress
   Flat affect
   Disorganized speech
       Incoherent or frequently veers off track
   Delusions
   Hallucinations
       Often auditory; sometimes visual
   Motor Movements
       May act upon hallucinations
      Profiles of
Schizophrenic Behavior
   Delusional:
       A man who wraps his house in tin foil
        to divert the rays from FBI satellites.
   Paranoid:
       The man introduces himself as Jesus
        Christ and tells you that the city
        council is out to crucify him.
        Profiles of Schizophrenic

   Disorganized (interview with a physician):
       “S____t on you all who rip into my internals!
        The grudgerometer will take care of you all! I
        am the Queen, see my magic, I shall turn you
        all into sidgelings forever!”
     Profiles of Schizophrenic

   Undifferentiated:
       Magical thinking
       Creates new words or cryptic language
       Cannot reason abstractly
      Diagnosis of Schizophrenia

   Two or more symptoms must each be
    present for a significant portion of each
    month over the course of 6 months.
   Sx must cause a social or occupational
   Most schizophrenics are diagnosed in early
    Approach To A Schizophrenic

   Be supportive
   Be nonjudgmental
   Don’t reinforce the patient’s hallucinations
    – but know that he considers them real
   Speak openly and honestly
   Be encouraging and realistic
   Be alert for aggressive behavior
   Restrain patient if necessary
    Anxiety Disorders

   Panic Attacks
       Acute, unprovoked episodes
       Last approximately 1 hour
       Symptoms:
          Cardiac chest pain, nausea
          Dyspnea or a sense of feeling “smothered”

          Fear of going crazy

          Paresthesia, dizziness

          Trembling, shaking
             Mood Disorders: Mania
   Sudden onset with rapid progression of
    symptoms (days)
   Presentation:
       Progressive inflation of self-esteem
       Distracted, racing thoughts
            Delusions may occur
       Very talkative with rapid speech
       Excessive involvement in high
        pleasure/high risk activities
     Management for anxiety
   Simple, supportive
   Be empathetic
   Assess medical complaints & tx prn
   Consider sedative
       Valium
       Versed
       Ativan
       Benadryl
           Bipolar disorder

   One or more manic episodes with or
    without depression, lasting at least one
   Not common
   Episodes often begin suddenly and
    escalate rapidly
   Disorder usually develops in adolescence
    or early adulthood
              The Stages of Mania
   Mild
       “On top of the world”
       Egocentric
       Decreased need for sleep
   Severe elation
       Rapid speech
       Illogical associations
       Delusions of grandeur
       Excessive involvement in pleasurable
        activities with high potential for
    Mood Disorders: Depression

   Situational vs. persistent
   Lack of interest in daily activities
   Altered mood impairs daily
   May be present with other
       Bipolar disease
       Substance abuse
    Presentation of Depression
   Bizarre behavior usually not seen in
   Inability to see beyond the person’s
    immediate situation
   Lethargy, slow thought process and
   Stooped posture
   Poor appearance
         General Management
   Behavioral crisis development and
    management are viewed as a “spectrum”
       Patients do not suddenly develop anger or
   Use the scene dynamics wisely to effect
    patient cooperation
   Never leave depressed or suicidal patient
           Management (cont.)

   Assess situation
   Protect self and others
   Summon law enforcement if necessary
   If no evidence of immediate danger, then
    one EMT responsible for assessing,
    treating and communicating with patient
   Transport with consent (when possible)
    without sirens
The Spectrum
When is it time for patient
   Use only when necessary
       Patient is a danger to themselves or others
       Look for all possible causes for the behavior
       Restraints must allow for adequate monitoring
        of vital signs
       Restraints applied by law enforcement must
        allow sufficient “slack”
   Patient must be able to straighten the abdomen
    and chest and take full breaths
   The officer must accompany the patient in the
   Approved equipment for prehospital personnel
   Padded leather
   Soft restraints (posey, velcro, seatbelts)
Unapproved Methods Of Restraint
   For Prehospital Personnel
   Hard plastic ties or device that requires a key to
   Backboard, scoop, or flat used to sandwich the
    “Hog - tied” (hands and feet behind the patient)
   Methods or material that could cause
    neurovascular compromise
   Evaluate and document the condition of the
    restrained extremity (neurovascular check)
    every 15 minutes.
     Documentation of Restraint
   Reason the restraints were needed
   Which agency applied the restraints
   Information and data regarding the
    monitoring of circulation to the restrained
   Information and data regarding the
    monitoring of respiratory status while
           Somatoform disorders

   Somatization disorder
       Pt is preoccupied with physical symptoms
   Conversion disorder
       Loss of function (blindness, paralysis)
   Hypochondriasis
       Exaggerated interpretation of physical
  and Behavior
      Neurotransmitters: Norepi

   Promotes awakening and enhances
   Elevates mood
   CNS locations: cortex, medulla,
    hypothalamus, limbic system, cerebellum
   NorEpi locations outside the CNS
   Mania and delusions with overstimulation
   Depression with low levels
    Neurotransmitters: Dopamine

   Stimulates emotional responses
   Controls subconscious skeletal movement
   CNS locations: cerebral cortex,
    hypothalamus and limbic system
   Schizophrenia and schizoid symptoms
    from amphetamines
     Neurotransmitters: Serotonin
   Controls sleep, sensory perception, mood
   Thermal regulation
   CNS locations: hypothalamus, limbic system
    and cerebellum
   Hallucinations with LSD and overstimulation
   Depression and anxiety with low levels
       Neurotransmitters: GABA

   Gamma aminobutyric acid
   Depresses mood and emotion
   CNS locations: everywhere!
   Enhanced by benzodiazepines
   Anxiety from low levels of GABA
Neurotransmitters and
   Drug Therapy
  Top prescribed Rx for 2004 & 2007

#6, 13 – Zoloft (SSRI)      #23, 16 – Ambien
#9, 98 – Zyprexa            #47, 19 – Welbutrin (SSRI)
     (Antipsychotic)        #53, 86 – Ablify
#13, 15 – Effexor XR (SSRI)      (Antipsychotic)
#18, 85 – Risperdal         #58, 1 – Paxil (SSRI)
     (Antipsychotic)        #69, 34 – Adderall
#19, 31 – Seroquel                      (Amphetamine)
        Additional Top Rx - 2003

   Alprazolam         Trazadone
   Lorazepam          Diazepam
   Clonazepam         Temazepam
   Prozac             Remeron (Serotonin stimulant)
   Amitryptiline      Concerta (amphetamine)
    Drug Therapies: Antipsychotics

   Phenothiazines and their derivatives
        Mellaril, Navane, risperidone, thorazine,
         stelazine, Prolixin
   Dopamine blockade
        Will produce a flatter affect
        Suppress hallucinations and delusions
        Side effects: hypotension, dystonic reactions
         Drug Therapies: Lithium

   Metallic compound
   Slows the elevated use of serotonin,
    norepi and dopamine in the synapse
       Slows sodium transport into the cell and
        reduces nerve transmission
   Effective for chronic control of mania
       In mania, sodium transport occurs 200%
        more than normal!
     Drug Therapies: TCA, MAOI
   Both work to keep norepinephrine in the
    synapse longer
       Elevates activity and mood in depression
   Anticholinergic effects
   Overdose
       Initially, massive amounts of norepi released
       Lack of reabsorption drops functional norepi levels
       Systemic effects!
          Drug Therapies: SSRI

   Keeps serotonin in the synapse

   Prozac, Paxil, Zoloft

   Overdose symptoms typically limited
            Serotonin Syndrome

   Medications that work in similar areas as
       TCAs and MAOIs
       Tramadol (narcotic)
       Meprobamate (Sedative-hypnotic)
       Promethazine
   Intense potentiation of SSRI effects
Medical Causes Of
Behavioral Crises
Clues Suggestive Of A Potential
Medical Cause Of The Behavior
   Abnormal vital signs
   Depressed level of consciousness
       Obtunded
   Evidence of drug or toxin ingestion
   Very sudden onset of symptoms
   Focal neurological signs
   No previous psychiatric history
   Presence of specific physical symptoms
A 24 year-old female was seen for manic-
type symptoms. She had irritability, rapid
speech and distracted conversation. These
symptoms had progressed over a 1-week

She had no history of mental illness or drug

Lab tests revealed a markedly high T4 level
and she was diagnosed with thyrotoxicosis.
A 28 year-old female with a history of
bipolar disorder was experiencing
significant withdrawal and depression.
She was apathetic with a flat affect and
did not seem to interact with things
around her. An hour after admission, she
was lethargic, nonresponsive and

Lab tests revealed lithium toxicity.
A 20 year-old was talking incoherently,
picking at her clothes and staring into
space. After she was admitted to the
hospital, her level of consciousness
rapidly deteriorated, becoming
disoriented and less responsive. She had
no history of psychiatric disease or drug
use. Her only history was that of herpes
After an EEG and lumbar puncture, she
was diagnosed with encephalopathy.

   9th leading cause of death overall
   3rd leading cause of death in 15-24 age
   Women attempt suicide more often, but –
    men are more often successful
Assessing Potentially Suicidal

   Perform appropriate H & E
   Provide appropriate psychological care
   Document observations, especially any
    detailed plans
        Risk factors for suicide
   Previous attempts
   Depression
   Age (15-24, & >40)
   Alcohol or drug abuse
   Divorced or widowed
   Giving away personal belongings
   Living alone/increased isolation
   Psychosis with depression
   Major separation trauma
   Major physical stresses
             Risk factors, cont.

   Loss of independence
   Lack of goals & plans for future
   Suicide of same-sexed parent
   Expression of a plan for suicide
   Possession of mechanism for suicide (gun,
    rope, pills)
           Age-related conditions
   Geriatrics
       You may mistake depression for dementia
       Assess their ability to communicate
       Provide reassurance
       Compensate for vision, hearing loss
       Treat with respect
       Avoid administering medication if possible
       Take your time
       Allow family & friends to be with patient
   Pediatrics
       Avoid separating young child from parent
       Make all explanations brief and simple; repeat
       Be calm, speak slowly
       Identify yourself
       Be truthful
       Encourage child to help with his care
       Don’t discourage child from crying, showing
       Allow child to keep favorite blanket or toy
   Peds, cont.
       Don’t leave child alone, even for short period
       If you must be separated from child,
        introduce care giver who will take over
    Management of Sudden Death
   Resuscitate patient unless obviously dead
   Keep family informed
   Be truthful
   Avoid trite phrases
   Do not offer false hope
   Empathize/sympathize
   Allow emotional response
   Maintain professionalism
     Management of terminally ill

   Do not isolate the family
   Allow feelings to be expressed
   Provide for patients physical comfort
   Allow for patients dignity in dying process
   Resuscitate according to local protocol
    regardless of a living will

   Many different reactions
       Cultural differences
   Denial
   Anger
   Bargaining
   Depression
   Acceptance
             How you doin’?

   Helplessness/Guilt
   Anger/Frustration
   Avoidance
   Nightmares
   Gallows humor
   Physiological response
           Can you cope?
 Rest
 Exercise

 Humor

 Hobbies

 Have a life outside of EMS

 Talk!

 Others?