Rosen & Barkin's 5-Minute Emergency Medicine Consult (687 page)

• For potentially dangerous patient who refuses transport to treatment facility; involve police and impose restraint.
  
• Risk to medics on the scene in cases of firearms or other weapons
  
• Know state and local laws, availability of mobile crisis units, and when to involve the police.
  

• Prevent ability to elope
  
• Ensure patient safety:
  
  • Remove sharp objects, belts, shoelaces, and other articles that could be used for self-injury
    
• Provide safe environment
  
• Appropriate supervision
  

• Confer with patient’s outpatient therapist or physician if possible
  
• Voluntary admission to psychiatric facility
  
• Involuntary admission if patient refuses voluntary
  
• For involuntary psychiatric admission, patient must have psychiatric disorder and 1 of the following:
  
  • Risk for danger to self
    
  • Risk for danger to others
    
  • Inability to care for self
    

Treat underlying psychiatric disorder.

FOLLOW-UP

• If patient endorses suicidal ideation with plan and intent, admission may be needed for safety.
  
• If impulsivity, anger, or aggression hinder ability to control behavior
  

• Patient has no suicidal ideation.
  
• Patient agrees to return to ED immediately or seek psychiatric help if suicidal ideation recurs.
  
• Patient has passive suicidal ideation without plan or intent.
  
• Patient has good support network or placement in appropriate crisis housing
  
• Appropriate outpatient psychiatric follow-up is ensured.
  
• In some cases, patients who express suicidal ideation while intoxicated may be discharged if no longer suicidal once they are sober.
  
• Some patients with borderline personality disorder and chronic suicidal ideation are discharged after careful psychiatric evaluation in consultation with long-term outpatient caregivers.
  

Close psychiatric follow-up for those with acute illness who do not require admission

• A careful history will identify risk factors for suicide.
  
• Access collateral sources of information about patient’s recent thoughts and behavior.
  
• Maintain patient safety during evaluation
  
• Hospital admission may be required if patient endorses suicidal ideation and plan.
  

• Ali A, Hassiotis A. Deliberate self harm and assessing suicidal risk.
  Br J Hosp Med (Lond)
  . 2006;67(11):M212–M213.
  
• Cooper JB, Lawlor MP, Hiroeh U, et al. Factors that influence emergency department doctors’ assessment of suicide risk in deliberate self-harm patients.
  Eur J Emerg Med
  . 2003;10(4):283–287.
  
• Miller M, Hemenway D. The relationship between firearms and suicide: A review of the literature.
  Clin Neurosci Res
  . 2001;1:310–323.
  
• Nock MK, Borges G, Bromet EJ, et al. Suicide and suicidal behavior.
  Epidemiol Rev
  . 2008;30:133–154.
  
• Ronquillo L, Minassian A, Vilke GM, et al. Literature-based recommendations for suicide assessment in the emergency department: A review.
  J Emerg Med.
  2012;43(5):836–842.
  
• Ting SA, Sullivan AF, Miller I, et al. Multicenter study of predictors of suicide screening in emergency departments.
  Acad Emerg Med.
  2012;19(2):239–243.
  

See Also (Topic, Algorithm, Electronic Media Element)

Depression

CODES

• 311 Depressive disorder, not elsewhere classified
  
• V17.0 Family history of psychiatric condition
  
• V62.84 Suicidal ideation
  

BASICS

• Rhythm that originates ectopically above the His bundle
  
• Heart rate of 100 bpm or greater
  
• Irregular narrow complex supraventricular tachycardia (SVT):
  
  • Atrial fibrillation (AF):
    
    • Most common form of pathologic SVT seen in the ED
      
    • 10% of people >75 yr of age have AF.
      
  • Atrial flutter with variable block
    
  • Multifocal atrial tachycardia
    
• Regular narrow complex SVT:
  
  • Atrial flutter
    
  • Atrioventricular nodal re-entry tachycardia (AVNRT):
    
    • 60% of SVT in adults, 70% are female
      
    • Typically present age 30–40 yr
      
  • Atrioventricular reciprocating tachycardia (AVRT) involving an accessory pathway
    
• Wide complex SVT:
  
  • Conduction is outside of the normal His-Purkinje system.
    
  • Accessory pathway or a bundle branch block is present.
    
  • More common in younger patients without structural disease
    
  • Always suspect a ventricular rhythm with a wide complex rhythm
    
  • Treat as ventricular tachycardia (VT) unless absolutely certain of SVT
    

• Atrial tachycardia:
  
  • Precipitated by a premature atrial or ventricular contraction
    
  • Electrolyte disturbances
    
  • Drug toxicity (i.e., theophylline)
    
  • Hypoxia
    
  • Increased atrial pressure
    
• Junctional tachycardia:
  
  • AV nodal re-entry
    
  • Myocardial ischemia
    
  • Structural heart disease
    
  • Pre-excitation syndromes
    
• Wolff–Parkinson–White (WPW) syndrome:
  
  • Intrinsic accessory pathway
    
  • Drug and alcohol toxicity
    
• AF:
  
  • HTN
    
  • Coronary artery disease
    
  • Hypo-/hyperthyroidism
    
  • Heavy alcohol intake
    
  • Mitral valve disease
    
  • Chronic pulmonary disease
    
  • Pulmonary embolus
    
  • WPW syndrome
    
  • Hypoxia
    
  • Digoxin toxicity
    
  • Chronic pericarditis
    
  • Sepsis
    
• Atrial flutter:
  
  • Ischemic heart disease
    
  • Valvular heart diseases
    
  • CHF
    
  • Myocarditis
    
  • Cardiomyopathies
    
  • Pulmonary embolus
    
  • Other pulmonary disease
    

DIAGNOSIS

• Palpitations (most common)
  
• Lightheadedness, pressure in the head
  
• Dyspnea
  
• Diaphoresis
  
• Dizziness
  
• Weakness
  
• Chest discomfort
  
• Syncope
  
• Prominent neck veins “frog sign”
  
• Signs of instability:
  
  • Mental status changes
    
  • Chest pain/ischemia
    
  • Acute pulmonary edema
    
  • Hypotension
    

• Abrupt onset of palpitations, lightheadedness, weakness, chest pain:
  
  • Current symptoms
    
  • Previous episodes
    
• Insidious onset of generalized weakness, exercise intolerance, and malaise
  
• Prior cardiac history
  
• Medications:
  
  • Over-the-counter, decongestants
    
• Illicit drug use
  

• Vital signs:
  
  • Tachycardia
    
  • BP normal or hypotensive
    
  • Respiratory rate normal or tachypneic
    
• Cardiac:
  
  • Regular or irregularly irregular rhythm
    
  • JVD may be present in setting of heart failure
    
• Pulmonary:
  
  • Rales may be present in setting of heart failure.