Psychiatric/Behavioral health emergency (< 18 years)



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Psychiatric/Behavioral health emergency (< 18 years)

Discharge criteria

  • Outpatient psychiatric action plan in place
  • Prescriptions for outpatient meds
  • Reassuring vital signs
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow
  • Patient/Caregivers comfortable and understand discharge plan
  • Medical provider and social work comfortable with outpatient therapy

Requires medical workup for source?

Need for chemical sedation?

Inclusion Criteria
  • Acute psychiatric concern (suicidal/homicidal ideation, psychosis, etc.)
  • Autism spectrum disorders or cognitive disabilities with acute exacerbation of symptoms
  • Active aggressive behavior
Exclusion Criteria
  • Acute, life threatening medical condition

Behavior posing acute risk to self or others?

Contact security, social work, place in a safe environment and attempt non-medical behavioral de-escalation techniques

Need for physical restraints?

Clinical suspicion based on H&P

Relief of acute agitation?

Relief of acute agitation?

Pediatric psychiatry consult

Pediatric psychiatry consult

Continued signs of psychosis?

Discharge

Lorazepam injection

Benzodiazepines in addition to olanzapine should be used with extreme caution as they can cause severe CNS/respiratory sedation.

Olanzapine injection
Olanzapine tabs

Haloperidol PO or injection + Diphrenhydramine

Diphenhydramine injection
Haloperidol injection
Haloperidol tabs

Complete appropriate workup

Off pathway, treat appropriately

Consider neurologic consult, off pathway

Will require psychiatric admission?

  • Arrange violent patient response team
  • Restrain patient per institution policy with leather restraints
  • Monitor patient per institution policy and remove restraints at earliest possible instance
  • Rotate location of restraint if patient in restraints for a prolonged period of time

Admit to psychiatric facility

Potential medical reasons for behavior/psychiatric emergency

  • Hypoglycemia
  • Hypoxia
  • Drug reaction/overdose/poisoning
  • Infection
  • Intracranial leasions
  • Encephalitis (autoimmune, infectious, etc.)
  • Metabolic complications
  • Others

Medical clearance laboratory workup should be individualized to the patient's symptoms. Although most testing in medically-asymptomatic patients is not useful, 'higher'-value tests commonly required by accepting psychiatric facilities are listed here.

Complete Blood Count, Serum
Complete Metabolic Panel, Serum
Urine Pregnancy, Urine
Alcohol Volatile Screen, Serum
Urine Toxicology, Urine
ECG
Acetaminophen, Serum
Thyroid-Stimulating Hormone (TSH), Serum

AAEP De-escalation Workgroup's 10 key elements for verbal de-escalation

  • Respect personal space - Two arm's lengths distance and space for easy exit for either party.
  • Do not be provocative - Non-confrontational, sincere body posture, do no stare, keep hands and relaxed
  • Establish verbal contact - Introduce all members of staff who are involved, but attempt to limit to one person as the main point of contact
  • Use concise, simple language - Avoid complex, elaborate and technical terms
  • Identify feelings and desires - Use free information to identify wants and feelings
  • Listen closely to what the patient is saying - Use active listening and restate what the patient says as a summary
  • Agree or agree to disagree
  • Lay down the law and set clear limits
  • Offer choices and optimism
  • Debrief the patient and staff