An Evidence-Based Approach to Emergency Department Patients at Risk for Posttraumatic Stress Disorder Symptoms (Trauma CME and Behavioral Health CME)

Table of Contents

 

About This Issue

The anxiety and stress from traumatic injury or a serious medical event can have long-term effects on patients’ recovery and future mental health. Although posttraumatic stress disorder (PTSD) cannot be diagnosed until 1 month post trauma, there are tools emergency clinicians can employ to screen for PTSD symptoms and strategies to help calm and reassure anxious patients. In this issue you will learn:

The full DSM-5 Diagnostic Criteria for PTSD

The protocol from The American College of Surgeons that will be required in 2023 for Level I and II Trauma Centers

What types of medical events can cause PTSD, and how it can manifest in patients in the short and long term

How a patient’s mental health history can affect their recovery trajectory

The screening tools for PTSD and their applications

The mental status examination and secondary prevention strategies

Using psychological first aid, trauma-informed care, violence intervention programs, gaming, and mobile apps in the ED

Organizational approaches to referral and follow-up

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Selected Abbreviations
6. Critical Appraisal of the Literature
7. Risk Factors for PTSD
   1. Comorbid Mental and Physical Health Conditions and PTSD
   2. PTSD and Severity of Traumatic or Medical Events
   3. PTSD Adjustment and Recovery Trajectories
8. Etiology And Pathophysiology
9. Differential Diagnosis
10. Prehospital Care
11. Emergency Department Evaluation
    1. Key Historical Questions
    2. Screening for Acute Psychological Distress
    3. Physical Examination
12. Diagnostic Studies
13. Treatment
    1. Secondary Preventive Intervention for PTSD Post Emergency Department Discharge
    2. Clinician Strategies to Reduce Distress in the Emergency Department
    3. Tertiary Intervention for Diagnosed PTSD: Psychotherapy and Pharmacological Interventions
    4. Organizational Approaches
14. Special Populations
15. Cutting Edge
    1. Early Intervention
    2. Mobile Devices and Gaming Strategies
16. Disposition
17. Risk Management Pitfalls for Emergency Department Patients at Risk for Posttraumatic Stress Disorder
18. 5 Things That Will Change Your Practice
19. Summary
20. Time- and Cost-Effective Strategies
21. Case Conclusions
22. Clinical Pathway for Assessing and Managing Posttraumatic Stress in Emergency Department Patients
23. Tables, Figures, and Appendix
24. References

Abstract

Approximately one-quarter of emergency department patients who are injured or experience medical emergencies will develop clinically significant posttraumatic stress disorder (PTSD) symptoms, which can evolve into PTSD. Emergency clinicians and rapid response teams (eg, trauma, cardiac, stroke) can play a critical role in recognizing symptoms of posttraumatic stress and providing early distress management techniques, screening, and referral to services that may mitigate the development of PTSD. This review summarizes the existing literature on psychological distress related to events that trigger the need for emergency care and synthesizes cutting-edge approaches that may impact patient outcomes.

Case Presentations

A 21-year-old woman with a stab wound to the arm is anxious, upset, and having difficulty focusing and answering questions…

• The patient recalls a similar violent injury from her past and appears to struggle to answer general questions from the treating team. There is a record of antidepressant medication in her chart.
• Her injuries are mild, and she is stable. After being evaluated by emergency clinicians and the surgical consult team, she remains anxious-appearing and tearful.
• You suspect that her recovery may be complicated, given her emotional state.
• You wonder whether a mental health consultation is indicated, and whether you can even get one on an emergent basis...

A 55-year-old man presents with chest pain and shortness of breath…

• The man is previously healthy with no history of cardiac problems.
• He is found to have a non-ST segment myocardial infarction (NSTEMI), following workup in the ED. He is started on antiplatelet therapy in addition to anticoagulation, and is admitted to the medical service for telemetry and possible catheterization.
• He is anxious during the ED evaluation and becomes tearful when told he is having a heart attack. “This is going to completely change my life. I’m so afraid I’m going to have another bigger heart attack.”
• You wonder whether there is any acute intervention that might mitigate his mental distress...

A 33-year-old woman presents to the ED following a motor vehicle crash involving a motorcycle…

• She struck her head during the accident, has slight photophobia, and is shaken up about the incident. She says she was afraid for her life and expresses concern for the other individuals involved in the crash.
• During the historical examination, she reports having experienced childhood adversity but appears to have adapted successfully with no prior intervention. Her wounds are primarily superficial, and following her secondary trauma survey, a CT scan of the head reveals negative findings. She is otherwise neurologically intact, and her plan includes discharge directly from the ED.
• When told of her results, she tells you, “I don’t think I can ever drive again…it’s just too frightening…I could have died.” While relieved that her trauma evaluation was reassuring, you wonder about some of the longer-term psychological effects of this event and whether there is anything that should be initiated in the ED . . .

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Clinical Pathway for Assessing and Managing Posttraumatic Stress in Emergency Department Patients

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Tables, Figures, and Appendix

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Edmondson D, Richardson S, Fausett JK, et al. Prevalence of PTSD in survivors of stroke and transient ischemic attack: a meta-analytic review. PLoS One. 2013;8(6):e66435. (Meta-analysis; 9 studies) DOI: 10.1371/journal.pone.0066435

7. Office of the Assistant Secretary for Planning and Evaluation US Department of Health and Human Services. Trends in the utilization of emergency department services, 2009-2018. 2021. Accessed December 10, 2022. (Report to US Congress)

8. * Kovalsky D, Roberts MB, Freeze B, et al. PTSD symptoms after respiratory and cardiovascular emergencies predict risk of hospital readmission: a prospective cohort study. Acad Emerg Med. (Prospective; 99 patients) DOI: 10.1111/acem.14438

9. * Bulger EM, Johnson P, Parker L, et al. Nationwide survey of trauma center screening and intervention practices for posttraumatic stress disorder, firearm violence, mental health, and substance use disorders. J Am Coll Surg. 2022;234(3):274-287. (Nationwide survey; 322 trauma centers) DOI: 10.1097/XCS.0000000000000064

10. Weathers FW, Litz BT, Davis MT, et al. The PTSD Checklist for DSM-5 (PCL-5). 2013. Accessed December 10, 2022. (PCL-5 scale checklist)

16. * Lowe SR, Ratanatharathorn A, Lai BS, et al. Posttraumatic stress disorder symptom trajectories within the first year following emergency department admissions: pooled results from the International Consortium to predict PTSD. Psychol Med. 2021;51(7):1129-1139. (Pooled analysis; 3083 participants) DOI: 10.1017/S0033291719004008

82. Brymer ML, C; Jacobs, A; National Child Traumatic Stress Network and National Center for PTSD. Psychological First Aid (PFA) Field Operations Guide, 2nd Edition. 2006; Accessed December 10, 2022. (Field operations guide)

84. American Psychological Association. Professional practice guidelines for evidence-based psychological practice in health care. 2021. Accessed December 10, 2022. (Evidence-based guidelines)

87. US Department of Health and Human Services. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. 2014. Accessed December 10, 2022. (Guidelines)

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Keywords: PTSD, posttraumatic stress, anxiety, intrusion, DSM-5, psychological first aid, trauma-informed care