Rosen & Barkin's 5-Minute Emergency Medicine Consult (310 page)

• Common tests:
  
  • CBC, serum chemistries
    
  • Ethanol, acetaminophen, salicylate serum concentrations
    
  • Urinalysis
    
• More focused studies depending on comorbid conditions or clinical concerns:
  
  • Urine drug of abuse screen
    
    • Interpretation can be difficult as this is a test of use and not intoxication. In addition, it is not designed to detect newer drugs of abuse, although some may cross-react with this assay.
      
  • EKG
    
  • Thyroid function
    
  • Liver function tests
    
  • RPR, folate, B
    ₁₂
    , thiamine
    
  • Specific drug concentrations
    

• Brain imaging (CT, MRI)
  
• Chest x-ray
  

• If suspicion exists for medical cause, should consider procedures such as:
  
  • Lumbar puncture
    
  • EEG
    
• If hallucinations are from acute psychiatric illness or decompensation of chronic psychiatric illness
  
  • Obtain emergent psychiatric consultation
    

Patients with a clear psychiatric history with characteristic symptoms need minimal testing (CBC, chemistries). However, patients with undifferentiated hallucinations, especially those in high-risk groups, require extensive testing.

The primary goal of ED evaluation is to differentiate psychiatric from nonpsychiatric cause of hallucination. (See Psychosis, Medical vs. Psychiatric)

• More likely to be from psychiatric illness:
  
  • Auditory and command hallucination
    
  • Hallucinations and illusions incorporated into delusional system
    
  • Age of onset 13–40 yr old
    
  • Flat affect
    
  • Normal orientation
    
  • Disorganized attention
    
• The following groups are considered to be at higher risk for nonpsychiatric illness:
  
  • Elderly
    
  • History of substance abuse
    
  • No pre-existing psychiatric history
    
  • Presence of pre-existing medical disorders
    
  • Lower socioeconomic level
    
• Visual hallucinations more common:
  
  • Delirium
    
  • Dementia
    
  • Migraines
    
  • Dopamine agonist therapy (i.e., carbidopa)
    
  • Posterior cerebral infarcts
    
  • Narcolepsy
    

TREATMENT

Observe details of patient’s environment not available to hospital care team

• Disorganized living environment
  
• Drug paraphernalia
  

• Address ABC’s and any abnormal vital signs (i.e., supplemental oxygen for hypoxia)
  
• Check FSBG
  
• Consider thiamine 100 mg IV/PO
  
• Treat acute agitation (see Agitation)
  
  • De-escalation techniques
    
  • Physical restraints
    
  • Chemical sedation
    

• If underlying medical cause identified
  
  • Treat medical etiology
    
  • These patients typically do not require antipsychotic medications
    
• In patients with acute psychosis or decompensation of chronic psychotic illness
  
  • Use antipsychotics and benzodiazepines (see Psychosis, Acute)
    
• In patients with hallucinations due to intoxication with excited delirium
  
  • General supportive care
    
  • Benzodiazepines
    
• If dementia with hallucinations
  
  • Treat underlying medical etiology, if any
    
  • Atypical antipsychotics have benefits and harm (CVA, extrapyramidal symptoms)
    

FOLLOW-UP

Disposition determined by medical condition or psychiatric evaluation. Hallucinations from some intoxications such as methamphetamine or cannabis may persist even after drug is metabolized.

• Medical condition requiring admission
  
• Acute psychiatric illness or decompensation of chronic psychiatric illness requiring psychiatric hospitalization
  

• Symptoms have resolved and reversible medical cause (i.e., intoxication, UTI)
  
• Decompensation of chronic psychiatric condition has been addressed, home environment appropriate and mental health follow-up available.
  

Alcohol/drug treatment as appropriate

As appropriate for medical or chronic psychiatric condition(s)

• Do not assume that auditory hallucinations are always from psychiatric illness whereas visual, tactile, olfactory, and gustatory hallucinations are nonpsychiatric – always perform thorough evaluation.
  
• Even though 10% of cases of schizophrenia occur in patients older than 45, do not assume hallucinations are from psychiatric cause in older age group without extensive workup.
  
• Do not treat hallucinations with excited delirium from an acute intoxication (except due to ethanol) with antipsychotic agents.
  

• El-Mallakh RS, Walker KL. Hallucinations, psuedohallucinations, and parahallucinations.
  Psychiatry.
  2010;73(1):34–42.
  
• Piechniczek-Buczek J. Psychiatric emergencies in the elderly population.
  Emerg Med Clin North Am.
  2009;24(2):467–490.
  
• Sood TR, Mcstay CM. Evaluation of the psychiatric patient.
  Emerg Med Clin North Am
  . 2009;27(4):669–683.
  
• Sosland MD, Edelsohn GA. Hallucinations in children and adolescents.
  Curr Psychiatry Rep.
  2005;7(3):180--188.
  

CODES

• 291.3 Alcohol-induced psychotic disorder with hallucinations
  
• 368.16 Psychophysical visual disturbances
  
• 780.1 Hallucinations
  

BASICS

• Predominantly alters perception, cognition, and mood
  
• All hallucinogens potentiate neurotransmitter release or bind directly to receptors:
  
  • Serotonin (5-hydroxytryptamine; 5-HT): Many hallucinogens are agonists or antagonists at 5-HT receptor subtypes.
    
  • Norepinephrine, N-methyl-D-aspartate (NMDA), dopamine
    

• Most exposures are intentional
  
• Common hallucinogens:
  
  • Indoleamine:
    
    • Lysergic acid diethylamide (LSD) (duration 6–12 hr)
      
    • Morning glory (Ipomoea spp.)
      
  • Tryptamines:
    
    • Psilocybin (Psilocybe mushrooms); frequently adulterated with LSD
      
    • N,N-dimethyltryptamine (DMT); 5-MeO-DMT (“foxy-methoxy”), and other tryptamine congeners
      
  • Phenylethylamines (hallucinogenic amphetamines):
    
    • Methylenedioxyamphetamine (MDA)
      
    • Methylenedioxymethamphetamine (MDEA)
      
    • Methylenedioxymethamphetamine (MDMA; “ecstasy”; duration 8–12 hr)
      
    • Paramethoxyamphetamine
      
    • Dimethoxyamphetamine
      
    • Mescaline (peyote cactus); frequently adulterated with LSD (duration 6–12 hr)
      
  • Arylcycloalkylamines:
    
    • Phencyclidine (PCP), (duration is variable 11–96 hr in 1 report)
      
    • Ketamine, (duration depends on route of administration 30–120 min)
      
  • Anticholinergic:
    
    • Deadly nightshade (
      Atropa belladonna
      )
      
    • Jimsonweed (
      Datura stramonium
      )
      
  • Other:
    
    • Piperazines: Benzyl piperazine (BZP) and trifluoromethyl phenylpiperazine (TFMPP)
      
    • Dextromethorphan (DXM), (duration 3–6 hr)
      
    • Marijuana
      

DIAGNOSIS