chemistry panel, urinalysis) performed. A CBC may indicate an infectious process, abnormal chemistries may

reveal hypoglycemia or hypo/hypernatremia, and urinalysis may provide evidence of a urinary tract infection.

Routine drug screens and alcohol levels are not useful and

should be reserved for patients with altered mental status

of unknown etiology. Patients with known psychiatric

illness and a consistent psychiatric presentation usually do

not require testing.

� Imaging

Imaging, like other testing, should be performed based on

clinical judgment. A noncontrast head computed

tomography scan is appropriate for patients with new

symptoms. A chest radiograph is indicated when a patient

has evidence of pneumonia or congestive heart failure.

Other imaging should be determined by the patient's

clinical condition.

PROCEDURES

Psychiatric patients are frequently agitated on presentation

to the ED and may pose a threat to themselves or the staff.

A stepwise progression of procedures is indicated to treat

agitation with the goal of avoiding the use of restraints.

The first step in treating the agitated patient is the process

of de-escalation. The essentials of de-escalation include

attempting to calm the patient, meeting their reasonable

CHAPTER 98

needs, and lessening environmental stimulation. The next

step to reduce a patient's level of agitation is to medicate

them with a benzodiazepine or anti-psychotic medication.

These medications include haloperidol (5 mg administered

intramuscularly [IM] ), atypical anti psychotics (ziprasidone

10 mg IM), and lorazepam ( 1-2 mg IM), alone or in

combination. The last step is restraining the patient in a

supine position with a restraint on each limb. Restrained

patients require frequent or continuous observation.

MEDICAL DECISION MAKING

History and physical examination, including a neurologic

and mental status examination, may be sufficient to

determine whether the patient has an acute psychiatric

illness. However, any abnormality noted from the history

and physical exam warrants further evaluation and treatment

looking for a medical etiology. Once medical issues have

been addressed, patients with ED presentation of psychosis,

depression, anxiety, suicidal, or homicidal ideation need an

appropriate psychiatric evaluation and disposition.

Patients with abnormal behavior from new-onset

delirium, dementia, or other medical illness require further

medical evaluation and admission (Figure 98-1).

TREATMENT

Treatment of the psychiatric patient in the ED varies. The

patient may need a refill of their psychotropic medication,

initiation of a new psychotropic medication, or emergent

treatment for acute agitation. Most emergency physicians

do not start patients on new psychotropic medications

without psychiatric consultation or primary care communication. All active medical problems should also be

addressed and treated.

DISPOSITION

� Admission

There are 3 universally accepted criteria to admit patients

with psychiatric illness: homicidal plan, suicidal plan, and

the inability to care for oneself. Clinical judgment is often

necessary to determine the need for admission in patients

with chronic suicidal or homicidal ideation, and patients

with other psychiatric illnesses and the potential inability

to care for oneself.

� Discharge

Patients discharged from the ED with psychiatric illness

need close follow-up by a professional. In many

communities there are limited psychiatric resources and

professionals to care for these patients. In communities

Schizophrenia

Bipolar illness

Depression

Delirium

Dementia

Hyperthyroidism

Head trauma

Temporal lobe epilepsy

Figure 98-1 . Overlapping conditions.

with limited psychiatric resources, these patients may be

referred to a primary care physician, allied health

professionals (nurse practitioner or physician assistant), or

community resources (social worker, case manager).

SUGGESTED READING

Zun LS. Behavioral Disorders: Diagnostic Criteria. In Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 20 11, pp. 1946-1 952.

Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg

Med. 2005;28:35-39.

Zun LS. Evidence-based treatment of psychiatric patient. J Emerg

Med. 2005;28:277-283.

A

AAA. See Abdominal aortic aneurysm

ABCDE mnemonic, for stroke, 359

Abciximab, for ACS, 55

Abdominal aortic aneurysm (AAA),

1 25-127, 126f, 127[

EUS for, 27-29, 28f, 29f

Abdominal pain, 1 1 2-1 1 7, 1 1 3t, 1 14f,

115f, 1 1 6f, 212-2 1 6, 2 1 3t,

214f, 215f

Abdominal trauma, 381-384, 382f, 383f,

385f, 386f

EUS for, 27-29, 28f, 29f

Abortion, spontaneous, 181-183,

1 82t, 1 84[

Abscess, 1 5 1-1 55, 1 53f, 154f

I&D for, 1-3, 1f, 2f

retropharyngeal, 206-2 1 0, 209f

Absence seizure, 353, 354t

Access to care, 30

Acetaminophen (APAP)

for fever, 140

for otitis media, 223

for pediatric fever, 204

for pharyngitis, 228

poisoning with, 233t, 239-243, 241f, 242f

for sickle cell disease, 301

for simple febrile reaction, 307

Acetazolamide

for acute angle-closure glaucoma, 323

for CRAO, 322

Acetylcholine, inhibition of, 255

Achilles tendon rupture, 399, 402

ACL. See Anterior cruciate ligament

Acromioclavicular joint widening, 392

ACS. See Acute coronary syndrome

ACTH. See Adrenocorticotropic hormone

Activated charcoal

for acetaminophen toxicity, 242

for CA overdose, 257, 258f

for digoxin toxicity, 253

for poisoned patient, 232-233, 232f

for salicylate overdose, 245, 246f

Active core rewarming, for hypothermia,

260, 261f, 262

Active external rewarming, for

hypothermia, 260, 261f

Acute abdominal pain, 1 1 2-1 1 7, 1 1 3t,

1 14f, 1 1 5f, 1 1 6f

Acute angle-closure glaucoma, 319-323,

32 1f, 322f

headache with, 337

Acute anterior uveitis, 315-3 1 8, 316t,

317f, 318[

Acute chest syndrome, 299, 302

Index

Acute cholecystitis, 12 1-124, 122f, 122t, 123f

EUS for, 27-29, 28f, 29f

Acute coronary syndrome (ACS), 50-56,

52f, 52t, 54[

chest pain in, 46-49, 48f

hypertensive emergency with, 76,

77t, 78t

Acute intravascular hemolysis, 304-307,

305t, 306f

Acute lung injury (ALI)

with salicylate overdose, 245

transfusion-associated, 304-307,

305t, 306f

Acute myocardial infarction (AMI),

50-56, 52f, 52t, 54[

Acute necrotizing gingivitis (ANUG),

328-330

Acute otitis media (AOM), 22 1-224,

222[, 223f

Acute retroviral syndrome (ARS), 156

Acute retroviral therapy (ART), 159

Acute rheumatic fever (ARF), pharyngitis

with, 225

Acute visual loss, 319-323, 320f,

32 1f, 322[

Acyclovir

for meningitis or encephalitis, 1 50

for pediatric fever, 204

Addison disease, 292-294, 294f

Adenosine, for dysrhythmia, 67, 69

ADH. See Alcohol dehydrogenase

Adolescents. See Pediatric patients

Adrenal crisis, 292-294, 294f

Adrenal emergencies, 292-294, 294f

Adrenal insufficiency, 292-294, 294f

a-Adrenergic receptor inhibition, with

CA, 255, 258

Adrenocorticotropic hormone

(ACTH), 292

Advanced Cardiovascular Life Support

protocols, for digoxin toxicity, 252

Advanced emergency medical technician

{AEMT), 30, 3lt

Advanced Trauma Life Support

guidelines, 358

AEIOU TIPS differential diagnosis, 334t

AEMT. See Advanced emergency medical

technician

AF. See Atrial fibrillation

Airborne precautions, for pneumonia, 103

Airway management, 37-41, 39f, 40f, 4 1f

for AMS, 333

for cardiopulmonary arrest, 34

for drowning incident, 270

for heat-related illness, 268, 269f

429

for hypothermia, 259

for poisoned patient, 232, 232f, 242,

248, 253

for seizure, 354

for stroke, 349

for trauma, 359

Airway obstruction, 206--211, 208f, 209f

Albuterol

for allergic reactions, 425

for asthma, 91, 92f, 93

for COPD, 97, 98f

for potassium disorders, 286

for respiratory distress, 210 f, 211

Alcohol dehydrogenase (ADH)

inhibition of, 237

poisoning with, 235

Alcohol withdrawal seizures, 356

Alcohols, toxic, 235-238, 236f, 237f

Aldosterone, 292

ALL See Acute lung injury

Alkalinization, urine. See

Urine alkalinization

Allen test, 5

Allergic eyelids, 316

Allergic reactions, 423-425, 424f, 425f

Allis maneuvers, 40 1

Alpha -agonists, for priapism, 1 78-179

Alpha-blockers, for nephrolithiasis, 169

Altered mental status (AMS), 332-335,

333t, 334f

with diabetic emergencies, 281

headache with, 337

with heat stroke, 268

with thyroid storm, 289

Alveolar osteitis, 328-330

American Society of Anesthesiologists

{ASA), physical status

classification of, 13, 13t

AMI. See Acute myocardial infarction

Amiodarone

for cardiopulmonary arrest, 34, 35f

for dysrhythmia, 69

Amoxicillin

for otitis media, 223

for pharyngitis, 228

Amoxicillin-clavulanate

for otitis media, 223-224

for UTI, 1 73t

Amphetamine, as toxidrome, 231t

Amphotericin B, for HN patients, 1 60

Ampicillin

for meningitis or encephalitis,

1 49-1 50, 149t

for pediatric fever, 204

for UTI, 1 73t

Ampicillin -sulbactam

for peritonsillar abscess, 228

for retropharyngeal abscess, 228

AMPLE mnemonic, 358-359, 382

AMS. See Altered mental status

Analgesics, procedural sedation with,

1 3-15, 13t, 14f, 14t, 1St

Anaphylactic shock, 42-45, 43 t, 44f

Anaphylaxis, 423-425, 425{

respiratory distress with, 207, 211

with urticaria, 307

Anesthetics. See also specific agents

for pediatric patients, 1 99

procedural sedation with, 13-15,

1 3t, 14f, 14t, 1 St

Angina, 50-56, 52f, 52t, 54{

Angioedema, 423-425, 424[, 425{

respiratory distress with, 207, 211

Angiography, for epistaxis, 324-325

Angiotensin-converting enzyme

inhibitors

angioedema with, 423-425, 424[

for CHF, 61

Anion gap

with acetaminophen toxicity, 240

for burns, 388

with CO poisoning, 248-249

with diabetic emergencies, 281

Ankle fracture, 400, 400[, 402

Ankle injuries, 398-402

Anterior abdomen, 38 1, 382[

Anterior cord syndrome, 369

Anterior cruciate ligament (ACL)

tears, 398

Anterior shoulder dislocation, 39 1,

391[, 396

reduction of, 395

Antibiotics

for acute cholecystitis, 123-124

after laceration repair, 23

anaphylaxis caused by, 423

for appendicitis, 1 19

for balanoposthitis, 1 80

for cervicitis and PID, 1 88 t

for conjunctivitis, 317

for COPD, 95, 97-98, 98f

for erythrodermas, 42 1

for fever, 138, 140, 140[

for hemorrhagic lesions, 422

for HIV patients, 1 59-160, 160{

for intestinal obstruction, 133

for mandible fractures, 330

for meningitis and encephalitis, 147,

149-150, 149[, 149t

for otitis media, 223

for pediatric fever, 203[, 204-205, 204t

for pharyngitis, 228

for pneumonia, 102, 103t

for sepsis, 144, 145f, 146

for septic arthritis, 412, 412{

for soft tissue infections, 151,

1 54[, 155

for UTI, 171, 1 72[, 1 73t

for vaginitis, 187t

Anticholinergic agents

for asthma, 92f, 93

INDEX

for COPD, 95, 97, 98f

for respiratory distress, 211

for RSI, 39

Anticholinergic toxidromes, 23 lt

antidote for, 233t

Anticoagulant therapy

for ACS, 54f, 55

acute abdominal pain and, 1 15

antidote for, 233t

complications with, 308-311, 310{

for PE, 48-49, 1 1 0, 111{

Antidotal therapy

for poisoned patient, 232f, 233, 233t

for toxic alcohol ingestion, 237, 237[

Antidysrhythmics, for cardiopulmonary

arrest, 34, 35f

Antiemetics

for acute cholecystitis, 123

for intestinal obstruction, 133

for nephrolithiasis, 167

Antifungals, for balanoposthitis, 180

Antihistamines

for allergic reactions, 423, 425, 425{

for dyspnea, 84, 87f

for shock, 44f, 45

for urticaria, 307

Antihypertensives

for hypertension in pregnancy, 191

for hypertensive emergency, 78, 78t

Antiplatelet therapy, for ACS, 48, 48[,

54f, 55

Antipsychotics, for psychiatric patient,

428