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Behavioral health emergencies most commonly present as depression, suicidal behavior, aggression, and severe disorganization. Emergency clinicians should avoid relying solely on past medical history or previous psychiatric diagnoses that might prematurely rule out medical pathologies. Treatments for behavioral health emergencies consist of de-escalation interventions aimed at preventing agitation, aggression, and harm. This issue reviews medical pathologies and underlying causes that can result in psychiatric presentations and summarizes evidence-based practices to evaluate, manage, and refer patients with behavioral health emergencies.
A 16-year-old adolescent girl presents to the ED after ingesting an entire bottle of ibuprofen 4 hours prior. The patient vomited a few times before arrival to the ED. Her initial vital signs are: temperature, 37°C (98.7°F); heart rate, 90 beats/min; blood pressure, 100/70 mm Hg; respiratory rate, 15 breaths/min; and oxygen saturation, 100% on room air. The girl is alert and oriented. Her physical examination is significant for mild epigastric tenderness and numerous well-healed bilateral cut marks on her wrists and thighs. A quick neurological examination reveals no abnormalities. The patient is a high school student who had excelled academically, but has had poor examination results recently. Her long-term boyfriend ended their relationship 1 week prior. The girl denies any substance use. She states that when she took the pills, she had wanted to kill herself because, “everything is horrible and overwhelming.” While you evaluate her privately, she does not make eye contact and remains silent when you ask about her current intent for suicide. You begin to think about the precautions you should take to keep this patient safe and what the next steps in the management should be...
A 15-year-old adolescent boy is brought to the ED by police because he threatened his mother with a knife. The police report states that he “trashed the house.” The patient’s mother arrives in the ED and states that their argument started because she would not allow her son to go out with a group of older friends whom she believes are a bad influence. She reports that her son has been abusing “oxy” that was initially prescribed following a football-related back injury. Since the injury, depression and truancy have been significant problems. The patient’s family history is concerning for both depression and substance abuse. When you evaluate the patient, he is diaphoretic and his pupils are dilated. Initially, he is cooperative and admits that he wants to “stop using the pills.” He adds that he has had transient thoughts of suicide but has never made a plan or attempted suicide. As you continue questioning the patient, his behavior begins to escalate and, despite redirection, he starts yelling. What should you do to ensure the safety of this patient and the ED staff? How should you respond if the patient’s aggressive behavior escalates further?
A 16-year-old adolescent girl presents to your ED. She has had 4 previous psychiatric hospitalizations for depression and, most recently, 1 for psychosis. Her medical workup for the new-onset psychosis at her last ED visit was negative. She was admitted to a psychiatric facility for 15 days and discharged on risperidone. Her parents called 911 because they state she has been acting very strangely, moving stiffly, and burning up with a fever. She is sweating, pale, and does not answer any questions. She appears to be disoriented, only responds to her name by looking at you briefly, is drooling, and appears tremulous. Her vital signs are: temperature, 41.5°C (106.7°F); heart rate, 132 beats/min; blood pressure, 144/88 mm Hg; respiratory rate, 26 breaths/min; and oxygen saturation, 100% on room air. As her evaluating physician, what would be your immediate concerns? What lab tests should you order? What consultations do you obtain in the ED?
Pediatric emergency department (ED) visits for behavioral health problems continue to rise, with rates doubling in the last decade. Recent reports confirm that this trend continues, with an increase of more than 40% from 2008 to 2013, from an initial rate of 9.3 behavioral health visits per 1000 ED visits to a peak of 13.7 behavioral health visits per 1000 ED visits in 2013.1,2 United States Department of Health and Human Services data indicate that 11.2% of children and adolescents aged between 2 and 17 years have a behavioral health or developmental condition.3 The prevalence of behavioral health problems leading to impairment peaks at 22.2% in the adolescent population, with up to 40% of these youth meeting criteria for more than 1 mental health condition.4 Recently published national trends in adolescent depression have also revealed a sharp increase, from 8.7% in 2005 to 11.3% in 2014.5 This is further complicated by the fact that, in the United States, about 2.3 million adolescents (9.4%) aged 12 to 17 years are involved in illicit substance use.6 Additionally, violence and suicide remain major problems in the adolescent population. Suicide is the second leading cause of death for persons aged between 10 and 24 years, resulting in 5491 lives lost in 2015. Homicide is the third leading cause of death for a similar age range, with 4733 victims reported in 2015.7
Despite the overwhelming healthcare needs of these children and adolescents, a serious shortage of community resources continues to lead to increasing ED visits for behavioral health–related causes.8 In a study of children and adolescents with serious mental illness and impairment, only 20% utilized specialty behavioral healthcare services in community settings.9 Additionally, despite American Association of Pediatrics (AAP) recommendations that pediatricians should identify risk factors for suicide, only approximately 10% of youth discuss these with their pediatrician, and this percentage has not changed in over a decade.10 For all of these reasons, the ED often becomes the first contact for many children and adolescents who present in a crisis and may require unique psychiatric evaluation, intervention, and coordination of after-care needs.11
After the first contact with triage, the emergency clinician is expected to gather the appropriate history, identify immediate medical needs, assess safety-related issues, obtain relevant laboratory work, arrange for appropriate consultations, and establish disposition planning.12 Additionally, different healthcare organizations/settings have different resources ranging from no available psychiatric care to telepsychiatry, an in-person psychiatric consultant, a dedicated behavioral health emergency team integrated within the ED, or a stand-alone psychiatric emergency service.13 This issue of Pediatric Emergency Medicine Practice reviews common clinical presentations of behavioral health emergencies, and provides a practical approach for best practices based on current evidence and established consensus guidelines.
A systematic search strategy was conducted in PubMed for a comprehensive review of the literature, using the following keywords in a Boolean search: child, children, adolescents, child and adolescent, pediatric, youth, behavioral, behavior, mental, mental health, psychiatric, altered, delirium, aggression, violence, suicide, emergency, and emergencies. After reviewing the titles and abstracts of 9068 records, 161 articles were selected for full text review. Criteria for inclusion were: (1) the study was conducted in a child or adolescent population, (2) there was presentation to an ED or management in an ED setting, and (3) there was a focus on violence, aggression, suicide, or delirium. Several review papers and retrospective studies were identified with a focus on epidemiology, presentations, disparities in access, etiology, comorbidity, investigations, management strategies, practice gaps, and policy guidelines. Very few randomized controlled trials comparing interventions were identified despite a broad-based search strategy and supplemental searches related to the population of interest in ED settings.
2. “I thought the patient’s tachycardia was due to his anxiety and odd behavior. I did not even notice his fever.”
Evaluating all of the patient’s vital signs in the ED is important. With behavioral health patients, tachycardia and fever may be a sign of NMS or serotonin syndrome, which are potentially lifethreatening conditions and cannot be missed.
9. “The kid’s mom says he does not like to do the things he used to do and now he won’t go to school. He clearly has depression.”
This patient is presenting with classic depression symptoms, but it is important to also rule out other potential issues, including drug use. Opioid misuse and addiction has become a national epidemic. Not identifying this cause of depression is a missed opportunity for potentially effective interventions. Initiating referral and connecting the patient to other resources may prevent the downward spiral of addiction and/or a life-threatening overdose in the future.
10. “This kid is out of control. Restrain him!”
Restraints are a high-risk procedure for patients and staff and should never be the first line of treatment. Environmental, verbal, and pharmacological interventions should always be attempted first; physical restraints should be utilized only in cases of imminent danger and failed interventions. When physical restraints are needed for severe agitation threatening the patient or staff, chemical restraint should be used with physical restraint to prevent selfinjury.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference:
Points & Pearls Excerpt
Most Important References
Vera Feuer, MD; Babar M. Saggu, MD; Jason M. Andrus, MD; Joshua Rocker, MD
Steven Rogers, MD, MS; Genevieve Santillanes, MD
January 8, 2018
February 1, 2021
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Behavioral Health CME and 1 Pharmacology CME credits
Date of Original Release: January 1, 2018. Date of most recent review: December 15, 2017. Termination date: January 1, 2021.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Other Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Behavioral Health CME and 1 Pharmacology CME credits, subject to your state and institutional requirements.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Feuer, Dr. Saggu, Dr. Andrus, Dr. Rocker, Dr. Rogers, Dr. Santillanes, Dr. Claudius, Dr. Mishler, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Dr. Jagoda made the following disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers Inc; Consulting fees, EB Medicine.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.
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