When every minute counts: What workup is sufficient for diagnosis under pressure?
Determining an exact diagnosis in the ED is less important than establishing a diagnostic category to guide emergency psychiatric treatment.
A pragmatic workup
Medical illnesses such as delirium, stroke, drug toxicity, or urinary tract infections can trigger or worsen psychiatric illness (Table 1).5 Comorbidities such as diabetes, hypertension, obesity, and heart disease are common in patients with psychiatric disorders, and psychotropics can cause or exacerbate these conditions.
In the high-pressure ED, a sufficient workup for complicated medical conditions lies somewhere between extensive/unnecessary and inadequate. Thus, determining an exact diagnosis is not as important as establishing a diagnostic category to guide emergency treatment.
Think of psychiatric disorders as they are organized in DSM-IV-TR—mood, anxiety, psychotic, substance use/withdrawal/intoxication, cognitive, adjustment, somatoform, and personality disorders—and whether they are primary or secondary to a general medical condition or substance use. For example:
- Anxiety disorder secondary to a general medical condition means the history, physical exam, or lab reports suggest a medical condition is the direct physiologic cause of the mood disturbance.
- Methamphetamine-induced psychotic disorder would be the diagnosis if methamphetamines are presumed to be causing a patient’s psychotic symptoms.
Hospitalization. ED staff often develop a treatment plan based on a patient’s clinical picture and a working diagnosis. The plan hinges on deciding if the patient needs to be admitted to the hospital. Admission may be warranted for life-threatening medical conditions or safety issues, such as threats to self or others or inability to care for oneself at home. Other issues come into play—such as starting or changing medications and follow-up to ensure continuity of care—if you decide to discharge the patient.
Even after medical clearance, patients in the psychiatric emergency service may have underlying medical illnesses (Table 2).6
Table 1
Medical disorders that can cause psychiatric symptoms
| Medical/toxic disorders | Examples |
|---|---|
| Alcohol and drugs of abuse | Amphetamines (including methamphetamine), cocaine, heroin, Jimson weed, ketamine, marijuana, MDMA (‘Ecstasy’), LSD, PCP |
| Prescription drugs | Antibiotics, anticholinergics, anticonvulsants, antihypertensives, benzodiazepines, chemotherapeutic agents, cimetidine, corticosteroids, digitalis, narcotics, propranolol, sleep medications, tricyclic antidepressants |
| CNS disease | Hypertensive encephalopathy, intracranial aneurysm, metastases, normal pressure hydrocephalus, postictal nonconvulsive status, primary CNS infection, seizure disorders, stroke, subdural hematoma, tumor |
| Infections | Acute rheumatic fever, diphtheria, malaria, Legionnaires’ disease, pneumonia, Rocky Mountain spotted fever, sepsis, syphilis, typhoid fever, urinary tract infection |
| Metabolic/endocrine disorders | Adrenal disease, diabetic ketoacidosis, hepatic encephalopathy, hypoglycemia, pituitary dysfunction, renal disease, serum electrolyte imbalances (sodium, potassium, calcium), thyroid disease, vitamin deficiencies, Wilson’s disease |
| Cardiopulmonary disease | Arrhythmias, congestive heart failure, COPD/asthma, myocardial infarction, pulmonary embolism |
| Miscellaneous | Anemia, lupus, multiple sclerosis, temporal arteritis, vasculitis |
| Source: Reprinted with permission from Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emerg Med Clin North Am 2000;18(2):185-90. Copyright 2000, Elsevier. | |
Table 2
Reasonable medical assessment in psychiatric emergencies
| DO |
| Obtain a medical history, the best determinant of medical need |
| Listen to patients. If they say they have a medical condition, believe them; if they say they don’t, try to believe them |
| Thoroughly check vital signs |
| Conduct a focused physical examination |
| Maintain a high index of suspicion |
Be selective with laboratory testing. Check:
|
| DON’T |
| Order blanket laboratory screening |
| Order an ECG in healthy young patients in the absence of clinical findings |
| Order chest radiography in the absence of known disease/exposure/symptoms |
| Source: Reprinted from Currier GW. Medical assessment on the psychiatric emergency service. Psychiatric Issues in Emergency Care Settings 2004;3(July):17, with permission from Cliggott Publishing Group of CMP Healthcare Media. Copyright 2004. |
Overwhelming demand
In the study of ED patient preferences,4 one-fifth of patients said they went to the ED because they lacked access to routine mental health care. Therefore, besides psychiatric conditions caused by medical illnesses, ED physicians can see patients with any primary psychiatric diagnosis, including mood and anxiety disorders and psychosis.
Under pressures of time and limited collateral information, ED staff must:
- individualize psychiatric treatment
- consider use of medications and/or restraints
- rule out life-threatening causes for psychiatric symptoms
- stabilize patients and prevent injury to self and others.
These tasks are becoming increasingly difficult as more and more patients present to emergency rooms. Nationally, ED visits increased from 19 million in 1992 to 108 million in 2000, according to the U.S. Department of Health and Human Services.1
Psychiatric patients are seeking ED care in greater numbers, and the number of those staying longer than anticipated (“boarding”) also has increased, according to a 2004 survey of 340 physicians by the American College of Emergency Physicians, American Psychiatric Association, National Mental Health Association, and National Alliance for the Mentally Ill. Surveyed physicians blamed inadequate Medicaid funding and bed shortages for the increasing ED visits.7
In crowded emergency rooms, where patients wait longer and longer to be seen, the influx of acutely ill psychiatric patients increases the risks of agitation, violence, and injury, as well as litigation.8
