Rosen & Barkin's 5-Minute Emergency Medicine Consult (581 page)

• Busch AL, Landau JM, Moody MN, et al. Pediatric psoriasis.
  Skin Therapy Lett
  . 2012;17:5–7.
  
• Cohen SN, Baron SE, Archer CB, et al. Guidance on the diagnosis and clinical management of psoriasis.
  Clin Exp Dermatol.
  2012;37(suppl 1):13–18.
  
• Feldman S, Dellavalle R. Treatment of psoriasis.
  www.uptodate.com
  . May 9, 2012.
  
• Feldman S, Dellavale R. Epidemiology, clinical manifestations and diagnosis of psoriasis.
  www.uptodate.com
  . October 9, 2012.
  
• Menter A, Korman N, Elmets CA, et al.. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical agents.
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CODES

• 696.0 Psoriatic arthropathy
  
• 696.1 Other psoriasis
  

BASICS

• Psychiatric “civil commitment”: The state-sanctioned
  involuntary
  hospitalization ofmentally disordered individual
  
• Voluntary psychiatry hospitalization: Voluntary psychiatric admission of competent adult who agrees to hospitalization
  
• Commitment criteria (review specific laws in your state):
  
  • Individual is mentally ill (many states exclude mental retardation, antisocial behavior, medical illness, and substance abuse)
    
  • Likelihood of serious harm defined as:
    
    • Substantial risk of physical harm to self
      
    • Substantial risk of physical harm to other persons
      
    • “Gravely disabled”: Inability to care for basic needs, including food, clothing, shelter, medical care, and safety
      
  • No less-restrictive alternative to hospitalization would attenuate risk
    
• 2 stages of commitment:
  
  • Emergency detention and admission (sometimes called emergency hold)—an emergency admission with minimum of legal process. Usually 72 hr
    
  • Longer-term commitment—requires judicial approval of continued confinement in an adversarial proceeding where patient may have legal representation
    

• Underlying genetic/biologic predisposition to psychiatric illness
  
• Precipitating psychosocial events can trigger onset or worsening of symptoms
  
• Substance abuse can worsen symptoms or lead to disinhibition causing worsening safety concerns
  

DIAGNOSIS

• Recent change in behavior or thinking
  
• Psychotic symptoms
  
  • Hallucinations
    
  • Delusions
    
  • Disorganized thought
    
• Panic, anxiety, or agitation
  
• Depressed mood
  
• Neurovegetative symptoms (disturbance of sleep, appetite, libido, energy, concentration, energy, psychomotor state)
  
• Manic symptoms (elevated or irritable mood, grandiosity, racing thoughts, excessive involvement in pleasurable activities at high potential risk)
  
• Specific evidence of commitment criteria:
  
  • Actual or threatened violence toward self
    
  • Actual or threatened violence toward others
    
  • Inability to care for self or protect self in the community
    
• Past psychiatric diagnoses, treatment, hospitalizations, history of harm to self or others
  
• Medication compliance
  
• Drugs of abuse: Amount and time of last use
  
• Access to weapons
  

• Signs of toxidromes/overdose
  
  • Slurred speech, ataxia (alcohol intoxication)
    
  • Tremor, nystagmus, diaphoresis, tachycardia (alcohol withdrawal)
    
  • Dilated pupils, piloerection, rhinnorhea (opiate withdrawal)
    
  • Hyperreflexia, myoclonus, diaphoresis, dilated pupils (serotonin syndrome)
    
• Signs of self-injury (scars, fresh wounds)
  
• Hypoactivity, rigidity, catalepsy, posturing (catatonia, NMS)
  
• Mental status exam
  
  • Expansive, irritable, or depressed mood
    
  • Disordered thought process, loose associations
    
  • Hallucinations
    
  • Delusions
    
  • Suicidal ideation (active vs. passive), intent, or plan
    
  • Homicidal ideation (identified target, intent, plan)
    
  • Impaired cognition (delirium, dementia)
    

• Thorough medical evaluation to rule out medical causes of change in thinking or behavior
  
• Psychiatric evaluation to clarify diagnosis and need for hospital level of care
  

• Basic screening labs for medical clearance as indicated by history and physical:
  
• Electrolytes, BUN, creatinine, glucose
  
• Liver function tests
  
• CBC and differential
  
• Toxicology screens and medication levels
  
• Urinalysis if infection suspected
  
• TFTs
  

CT or MRI of head if injury or structural CNS pathology suspected

• EEG if seizure/postictal state suspected
  
  • Repetitive pattern
    
  • Aura usually somatosensory psychiatric autonomic symptoms
    
  • Postictal period of either confusion or dysphasia
    
• LP
  
  • Fever or nuchal rigidity
    
  • Seizures
    

• Substance intoxication or withdrawal
  
• Delirium
  
• Dementia
  
• Traumatic brain injury/subdural
  
• Temporal lobe seizures
  
• Encephalitis
  
• Meningitis
  
• Antisocial behavior (patient feigning psychiatric symptoms, homicidal or suicidal ideation to obtain medications or shelter or avoid arrest)
  

TREATMENT

• Patient or concerned family may call the ED and describe an emergency circumstance
  
• Depending on state, police, social worker, psychologist, or psychiatrist can send patient to ED for emergent assessment and possible involuntary hospitalization
  
• EMTs can restrain and bring patient to hospital involuntarily with appropriate legal paperwork
  

• Ensure patient and staff safety
  
  • Make sure patient does not have weapon or medications
    
  • Room without hazards (sharps, medications, etc)
    
  • Constant observation to prevent elopement
    
• Assess for overdose or self-injury requiring immediate treatment
  
• Ensure that proper legal paperwork is in place to hold patient in the ED
  

• Medical workup and clearance
  
• Psychiatric consultation, if available
  
• Determine if patient requires psychiatric hospitalization.
  
• Restrain patients at risk of harming themselves or others, using least restrictive means required to maintain safety:
  
  • Nurse or security guard standing outside room
    
  • Pharmacologic restraint given PO, IM, or IV
    
  • Physical restraints
    
• Continue patient’s confirmed home medications if appropriate
  
• Offer symptomatic medications such as antianxiety, antipsychotic, or sleep aid as needed
  
• Treat alcohol or drug withdrawal as needed
  

• First line is Olanzapine 5--10 mg PO/IM OR haloperidol 5 mg IM with lorazepam 2 mg IM and benztropine 1 mg IM.
  
• First Line for EtOH/BZP withdrawal:
  
  • Diazepam 5–10 mg PO q1h prn (monitored with standardized symptoms assessment such as CIWA scale)
    
• 1st line for delirium not associated with alcohol withdrawal or anticholinergic excess:
  
  • Haloperidol 1–2 mg PO/IM/IV
    
• 1st line for agitation not associated with psychosis, delirium, or alcohol withdrawal:
  
  • Lorazepam 1 mg PO/IM/IV
    

FOLLOW-UP