BEHAVIORAL EMERGENCIES DAN MUSE MD BEHAVIORAL EMERGENCIES DEFINITION

BEHAVIORAL EMERGENCIES DAN MUSE, MD

BEHAVIORAL EMERGENCIES DEFINITION • Walter Payton`s father, Edward, died at 54 in 1979 under circumstances that are not clear. Arrested by a young, white policeman for driving while intoxicated, he was put in Columbia`s jail to ``dry out`` and was found dead a few hours later.

BEHAVIORAL EMERGENCIES DEFINITION • The coroner found no traces of alcohol or drugs and said he died of a cerebral hemorrhage. A courtordered autopsy cleared local officials of wrongdoing.

BEHAVIORAL EMERGENCIES DEFINITION BEHAVIORAL EMERGENCY: a temporary change in behavior or exacerbation of a chronic underlying behavioral disorder that results in a threat to the patient or others.

BEHAVIORAL EMERGENCIES are a specific subset of altered mental status.

AMS ALTERED MENTAL STATUS IS A SYMPTOM AND NOT THE DIAGNOSIS CAUSES 1. 2. INFECTION: Meningitis, Sepsis 3. 4. METABOLIC: Hypoglycemia, Hyponatremia 5. 6. PSYCHIATRIC: Psychosis, Bipolar…. . STRUCTURAL: Stroke, Trauma, Seizure INGESTIONS: Narcotics, Alcohol, PCP…… CONGENITAL/GENETIC

AMS PNEUMONIC • A – Alcohol • E – Epilepsy • I - Insulin • O – Opioids /Drugs • U - Uremia • T – Trauma, Temperature • I – Infection • P – Poisonings • P – Psychiatric • S – Stroke, Shock

ALCOHOL 8

BEHAVIORAL EMERGENCIES ALCOHOL • Results in behavioral changes by itself • In the inebriated state we oftentimes see personality changes….

NOT ALL DRUNKS ARE THE SAME 10

QUIET DRUNK

MATH CLUB DRUNK

MAKE YOUR MOTHER PROUD DRUNK

GUY FANTASY DRUNK

THE ASSHOLE DRUNK

BEHAVIORAL EMERGENCIES ALCOHOL • The drunk asshole • We all know him and some of us have been him. • There is usually a sense of importance. • They are argumentative and believe they are always right • They can become destructive and violent.

BEHAVIORAL EMERGENCIES ALCOHOL EXCEPT FOR THE VIOLENT BEHAVIOR, THEY ACT LIKE……. 17

A FIRE CHIEF!!!!! 18

https: //www. youtube. com/watch? v=C 0 Wu 7 SQ 6 jiw

BEHAVIORAL EMERGENCIES ALCOHOL • The drunk asshole is a temporary but oftentimes a recurring condition.

BEHAVIORAL EMERGENCIES ALCOHOL • Drops in alcohol may result in seizures and delirium in chronic alcoholics • Either a seizure and a post-ictal state or delirium can result in behavioral changes which may cause the patient to be a threat to himself.

SEIZURES 22

BEHAVIORAL EMERGENCIES EPILEPSY (SEIZURE) • INTRINSIC SEIZURES • STRUCTURAL: Space occupying; tumor, bleed, edema. • HYPOXIA. • POISONINGS: INH • METABOLIC: Hypoglycemia, Hyponatremia • INFECTION: Meningitis; Febrile Seizures • PSYCHIATRIC: Pseudo-seizures

TYPES OF SEIZURES EPILEPSY FOUNDATION • Absence Seizures • Complex Partial Seizures • Atypical Absence Seizures • Secondarily Generalized Seizures • Atonic Seizures • Febrile Seizures • Clonic Seizures • Nonepileptic Seizures • Myoclonic Seizures • Refractory Seizures • Tonic Seizures • New Terms and Concepts for Seizures and Epilepsy • Tonic-Clonic Seizures • Simple Partial Seizures • Gelastic and Dacrystic Seizures

ABSENCE SEIZURE • Absence seizures are lapses of awareness, sometimes with staring. • They begin and end abruptly, lasting only a few seconds. • More common in children. • Absence seizures can be so brief that they sometimes are not detected for months.

ABSENCE SEIZURE • Simple absence seizures: During a simple absence seizure, a person usually just stares into space for less than 10 seconds. Because they happen so quickly, it’s very easy not to notice simple absence seizures — or to confuse them with daydreaming or not paying attention.

ABSENCE SEIZURE • Complex absence seizures: During a complex absence seizure, a person will make some kind of movement in addition to staring into space. Movements may include blinking, chewing, or hand gestures. A complex absence seizure can last up to 20 seconds.

https: //www. youtube. com/watch? v=e. H-e. EE 52 F 6 Y

SIMPLE PARTIAL SEIZURES • Simple partial seizures can be motor seizures that cause change in muscle activity. • These seizures can be sensory seizures that cause changes in any one of the senses. • These seizures can be autonomic seizures that cause changes in the part of the nervous system that automatically controls bodily functions. • These seizures can be psychic seizures that change how people think, feel, or experience things.

https: //www. youtube. com/watch? v=ve. Infvb-c. Es

COMPLEX PARTIAL SEIZURE • Complex partial seizures last 1 to 2 minutes. • These seizures may have an aura (or warning). • Complex Partial Seizures include automatisms (such as lip smacking, picking at clothes, fumbling), unaware of surroundings or may wander.

https: //www. youtube. com/watch? v=hyj 7 MSda. Lqw

DIABETES 33

AMS DIABETES • Hypoglycemia • Results in cognitive impairment. • Behavior can be dull, somnolent, and confused. • It can also result in confusion and agitation.

AMS DIABETES • Checking for a low blood sugar is always part of the AMS evaluation

DRUGS 36

DRUGS • Drug abusers oftentimes have underlying psychologic issues. • The combination can result in behavioral changes that can result in potential harm to themselves and/or others.

DRUGS NARCOTICS • Use of narcotics result in a sedative state. • Withdrawals or use of naloxone result in agitation • This in turn cause aggressive behavior.

COCAINE • A stimulant • Causes elevated heart rate and blood pressure • Can become agitated • May develop psychosis • Can result in vascular events; head bleed, heart attack

COCAINE • CNS effect depends on amount used and to some extent the personality of the person • Manic behavior and euphoria may occur • Psychosis with delusions, paranoia and hallucinations are possible.

DISSOCIATIVE AGENTS • Drugs such as PCP (phencyclidine) and ketamine, were initially developed as general anesthetics for surgery • Distort perceptions of sight and sound and produce feelings of detachment (dissociation) from the environment and self.

DISSOCIATIVE AGENTS • These mind-altering effects are not hallucinations. • Pcp and ketamine are therefore more properly known as "dissociative anesthetics. "

DEXTROMETHORPHAN • Dextromethorphan, a widely available cough suppressant, when taken in high doses can produce effects similar to those of pcp and ketamine.

PCP PHENCYCLIDINE • PCP is a synthetic hallucinogen. • Used for recreational purposes • Has the ability to cause the user to feel invulnerable and exceptionally strong • Is sometimes mixed in marijuana

PCP PHENCYCLIDINE • The drug also cause analgesia and extremity numbness. • Combined with the hallucinations and sense of superhuman strength, these patients are cause for major trauma to themselves and those trying to restrain them.

PCP PHENCYCLIDINE

HALLUCINOGENS • Hallucinogens are natural and synthetic drugs that create a distortion of ones senses. • A person may see, hear feel things that are not real. • How they react to these hallucinations dictates what they may do to themselves and others

HALLUCINOGENS • Lysergic acid diethylamide (LSD) and psilocybin mushrooms are two examples of synthetic and natural hallucinogens. • Indian tribes use the mushrooms for religious practices.

PREVALENCE OF STUDENTS WHO HAVE USED HALLUCINOGENS AND PCP Source: Monitoring the Future Survey, 2000 Note: Data not available for PCP Prevalence for 8 th and 10 th graders

METHAMPHETAMINE • Synthetic drug that is easily made on the streets. • Highly addictive and leads to long term health and psychiatric issues.

METHAMPHETAMINE • Classified as a stimulant and has similar properties such as cocaine. • Causes a surging euphoria on initial use • Addiction is strong which leads to the chronic health and psychological issues

METHAMPHETAMINE • Chronic use can lead to structural changes in the brain that affect motor and memory • Psychiatric issues such as emotional lability, paranoia and hallucinations can occur.

METHAMPHETAMINE • Meth "cooks" use most or all of the ingredients below to make methamphetamine. Most all of the ingredients below come with a warning label telling the consumer not to ingest the product. Meth manufacturers don't include this warning on their finished product. • ALL INGREDIENTS CAN BE BOUGHT AT WALMART!

METH INGREDIENTS GASOLINE ADDITIVES RUBBING ALCOHOL ETHER (STARTING FLUID) BENZENE PAINT THINNER FREON ACETONE CHLOROFORM CAMP STOVE FUEL Anhydrous ammonia White gasoline Pheynl-2 -Propane Phenyl-acetone Phenylpropanolamine Rock, table or Epsom salt Red Phosphorous Toluene (found in brake cleaner) Red Devil Lye Drain cleaner Muraitic acid Battery acid Lithium from batteries Sodium metal Ephedrine Cold tablets Diet aids Iodine Bronchodialators Energy boosters Iodine crystals

FACES OF METHAMPTHETAMINES

FACES OF METHAMPHETAMINE

METH MOUTH

FACES OF WALMART

BATH SALTS • Synthetic cathinones or stimulants. • Natural plant they derive from is KHAT. • Methylenedioxypyrovalerone (MPDV), mephedrone and methylone are the chemicals most often found in bath salts • Can be smoked, snorted, shot up 67

BATH SALTS Bath salts are sold under a number of different “brand” names, and as different products, such as plant feeder or insect repellent. Brand names include: bliss, blue silk, cloud nine, drone, energy-1, ivory wave, lunar wave, meow, ocean burst, pure ivory, purple wave, red dove, snow leopard, stardust, vanilla sky, white dove, white knight and white lightning 68

BATH SALTS RESULTS IN “STIMULATED” BEHAVIOR • Paranoia and violent behavior • Hallucinations • Delusions • Suicidal thoughts • Seizures • Panic attacks • Increased blood pressure and heart rate • Chest pain • Nausea and vomiting 69

SYNTHETIC MARIJUANA • Common Names: Spice, K 2, No More Mr. Nice Guy, ……. • “Synthetic Marijuana” Is Very Different From Marijuana. • They Contain Powerful Chemicals Called Cannabimimetics 70

SYNTHETIC MARIJUANA • Made by spray chemicals that have properties “similar” to THC • Sold as incense and “not for human ingestion” on label • Felt to be very addictive 71

SYNTHETIC MARIJUANA K 2 is typically sold in small, silvery plastic bags of dried leaves and marketed as incense that can be smoked. It is said to resemble potpourri. 72

SYNTHETIC MARIJUANA SIDE EFFECTS…… • Severe agitation and anxiety. • Fast, racing heartbeat and higher blood pressure. • Nausea and vomiting. • Muscle spasms, seizures, and tremors. • Intense hallucinations and psychotic episodes. • Suicidal and other harmful thoughts and/or actions. 73

PSYCHOSIS 74

PSYCHOSIS • Psychosis is a disturbance in the perception of reality, evidenced by hallucinations, delusions, or thought disorganization. • Psychotic states are periods of high risk for agitation, aggression, impulsivity, and other forms of behavioral dysfunction.

PSYCHOSIS HALLUCINATIONS • Hallucinations are false sensory perceptions occurring in any of the five sensory modalities. • Hearing Sight Touch Smell And Taste • Auditory hallucinations are the most common, followed by Visual, Tactile, Olfactory, And Gustatory.

PSYCHOSIS DELUSIONS • DELUSIONS — False beliefs that are firmly held despite obvious evidence to the contrary, and not typical of the patient's culture, faith, or family. • Persecutory, Grandiose, Religious, Somatic, and other delusions are all common.

PSYCHOSIS THOUGHT DISORGANIZATION • Disruption of the logical process of thought may be represented by loose associations, nonsensical speech, or bizarre behavior. • These symptoms are typically accompanied by a high level of functional impairment and high risk for agitated and aggressive behavior.

PSYCHOSIS AGITATION • Agitation is an acute state of anxiety, heightened emotional arousal, and increased motor activity. • Agitation is common in a variety of psychiatric and medical conditions, and frequently accompanies psychosis.

PSYCHOSIS AGITATION • Agitation may be worsened by the psychotic patient's awareness of deteriorating thought organization, disturbing delusional thoughts, or tormenting voices. • External factors may include the unwelcome intrusion of medical or law enforcement personnel attempting to aid the patient.

PSYCHOSIS AGGRESSION • Acts or threats of violence are common in acute psychotic states, especially in patients with persecutory delusions, thought disorganization, and poor impulse control

PSYCHIATRIC DISORDERS

SCHIZOPHRENIA • SCHIZOPHRENIA — Schizophrenia is a severe, chronic disorder characterized by periods of active psychosis and persistent deterioration in social, occupational, scholastic, and personal functioning.

SCHIZOPHRENIA

BIPOLAR MANIA • A manic episode is a discrete, sustained period of elevated or irritable mood, decreased need for sleep, increased activity, rapid thought and speech, grandiosity, and poor judgment that might place • The patient at risk for injury to self or others, loss of reputation, financial impropriety, or sexual indiscretion. • About 80 percent of untreated manic patients develop psychotic symptoms.

BIPOLAR MANIA

MAJOR DEPRESSION WITH PSYCHOTIC FEATURES • Psychotic features may be found in patients with major depression, occurring at least as commonly as bipolar disorder or schizophrenia

SCHIZOAFFECTIVE DISORDER • Schizoaffective disorder is a condition in which the patient meets the diagnostic criteria for both schizophrenia and a major mood disorder

ALZHEIMER DISEASE • As many as 40 percent of patients with Alzheimer disease experience psychotic symptoms, primarily delusions, and visual hallucinations

DELIRIUM • Delirium is an acute disturbance of consciousness and cognition characterized by inability to focus or maintain attention, disorientation, memory impairment, and language disturbance. • Delirium is most often the consequence of a medical condition, substance intoxication, or medication side effect.

EXCITED DELIRIUM • • First described in 1849 in patients showing agitation and mania in the face of a fever. This was followed by sudden collapse and death.

EXCITED DELIRIUM ASSOCIATED WITH COCAINE (AND OTHER STIMULANT) USE AND IS THOUGHT TO BE THE CAUSE OF APPROXIMATELY 10% OF COCAINE DEATHS Excited Delirium and Sudden Unexpected Death Matthew D. Sztajnkrycer, MD, Ph. D Amado A. Baez, MD, MSc Department of Emergency Medicine Mayo Clinic Rochester, MN

EXCITED DELIRIUM APPEARS TO HAVE 4 DISTINCT STAGES 1. ELEVATED TEMPERATURE 2. AGITATED DELIRIUM 3. RESPIRATORY ARREST 4. DEATH

EXCITED DELIRIUM • • • Excited delirium death is not well understood Thought to be to effects on dopamine receptors resulting in temperatures and delirium and adrenergic surges FINAL PHASE PRIOR TO DEATH IS FELT TO BE RESPIRATORY COLLAPSE

EXCITED DELIRIUM • • • Highly agitated individuals especially those who are known to use cocaine should be seen in the emergency department Check to see if the patient is warm and if possible take their temperature. WATCH CLOSELY THEIR RESPIRATORY STATUS

PSYCHOSIS 96

PSYCHOSIS SECONDARY TO A MEDICAL CONDITION • NEUROLOGIC PROBLEMS: CNS Infections, Neoplasms, Vascular Events, Cognitive Disorders, And Seizures • ENDOCRINE DYSFUNCTIONS: Thyroid, Parathyroid, Or Adrenal Abnormalities • METABOLIC PROBLEMS: Hypoxia, Hypercarbia, Hypoglycemia, Fluid Or Electrolyte Abnormalities, Aberrant Copper Clearance. • Hepatic And Renal Disorders • AUTOIMMUNE DISORDERS: Systemic Lupus Erythematosus

SUICIDE 98

SUICIDE • Each year, about 30, 000 people in the united states and one million worldwide die by suicide. • 650, 000 people in the united states receive emergency treatment each year after attempting suicide

SUICIDE • Suicides are under estimated as threats to ems. • The idea is that they want to only kill themselves • A person who really wants to die may have no qualms against killing others in order to accomplish their goal.

SUICIDE BY COP • QUINCY, Mass. — Police shot and killed a 65 -yearold Quincy man yesterday after he attacked officers with a knife as they responded to a report of an attempted suicide, authorities said. • Police and an emergency unit responded to a 911 call at about 10 a. m. and found James Hart with selfinflicted knife wounds inside a small shed on Grand View Avenue , Norfolk District Attorney William R. Keating said during a press conference yesterday. When officers tried to force Hart out of the small structure with a chemical spray, he ran out and attacked with a 12 -inch kitchen knife, Keating said. • "Mr. Hart lunged at two of the officers while urging them to shoot him, " Keating said.

SUICIDE BY COP • "The evidence clearly indicates the shooting was justified, " Keating said. • Boston Globe, July 4, 2007

SUICIDE BY COP • Coined term for someone who forces others into killing them because they want to die.

EMS VIOLENCE 104

EMS VIOLENCE • EPIDEMIOLOGY — Up to 50 percent of healthcare providers are victims of violence sometime during their careers [1, 2]. • A 2008 survey of over 3500 United States (US) emergency department (ED) clinicians at 65 sites reported that 3461 physical attacks occurred over a five year period.

EMS VIOLENCE • Approximately 4 to 8 percent of patients who present to psychiatric emergency departments (ED) are armed [9, 10]. • At one large urban county hospital ED in the us, an average of 5. 4 weapons were confiscated each day using metal detector screening [11]. • At this center, 26. 7 percent of major trauma patients seen in the ED over a 14 year period were armed with lethal weapons (84 percent knives and 16 percent guns).

EMS VIOLENCE • A 1997 study found that 61% of EMS personnel surveyed had been assaulted, and 25% of them were injured as a result. • A 1998 study showed that violence preceded 14% of EMS calls and that EMS personnel surveyed were victims of violence during 5% of calls. • This study confirmed that violence against EMS providers is underreported

EMS VIOLENCE • DOMESTIC DISPUTES • Typically violence has already occurred • Emotions are high and there are usually two sides • EMS can be caught in the middle and the anger can be turned on them.

EMS VIOLENCE • CHILD AND DOMESTIC ABUSE • If a family member feels that EMS is going to involve government agencies to investigate, it is not uncommon for that person lash out on the EMS personnel

EMS VIOLENCE • Drunk crowds can quickly turn in to lynch mobs.

MANAGEMENT

MANAGEMENT PROTECT YOURSELF AT ALL TIMES • USE AVAILABLE RESOURCES • CONTROL THE SCENE • ALWAYS BE CALM • USE PERSUASION OVER FORCE 112 69

MANAGEMENT PROTECT YOURSELF AT ALL TIMES ARE YOU ENTERING A HOSTILE ENVIRONMENT? • Domestic Violence • Gang Violence • Drunks At A Party Or Bar. • While you are not there to care for them, the bystanders can turn on you especially when drugs and alcohol are mixed with angry emotions. 113

MANAGEMENT PROTECT YOURSELF AT ALL TIMES DO YOU HAVE THE APPROPRIATE PROTECTIVE EQUIPMENT? • Gloves? • Masks? • Flak Jacket? ? ? 114 71

MANAGEMENT PROTECT YOURSELF AT ALL TIMES DOES THE PATIENT HAVE A WEAPON? • Club? • Glass? • Knife? • Gun? • Needle? • Open Bleeding Wounds? • Saliva. . . . ? 115 72

MANAGEMENT PROTECT YOURSELF AT ALL TIMES • ALWAYS PRESUME THERE IS A CONCEALED WEAPON! 116 73

MANAGEMENT • Never enter a hostile (or potentially hostile) situation by yourself. • Let the police secure the scene first. • This could mean a delay in treating the patient, and. . . So be it. 117 74

MANAGEMENT USE AVAILABLE RESOURCES • NEVER ATTEMPT TO TREAT A PERSON WHEN THERE ARE POTENTIAL DANGERS TO YOU. • • • An electrocution with a live wire still exposed. Fall off a cliff HAZMAT i. e. meth lab 118 75

MANAGEMENT USE AVAILABLE RESOURCES • DON’T FORGET MEDICAL CONTROL • • • Section 12 Sedation Pronouncement 119 76

MANAGEMENT CONTROL THE SCENE • LET PROFESSIONALS DO THEIR JOB • Police handle the crowd, subdue assholes and maintain the flow in and out of the area. • Fire handles the fires, extracation and hazmats. 120 77

MANAGEMENT CONTROL THE SCENE • EMT’S HANDLE PATIENT CARE • Evaluation and treatment of the patient is the emt’s primary responsibility. • Delegating resources is the secondary responsibility. • In the field, the emt is in charge of patient care. If there are people who want to help, the senior emt determines if they can participate. 121 78

MANAGEMENT ALWAYS BE CALM • IF YOU ARE NOT CALM, THOSE AROUND YOU WILL NOT MAINTAIN THEIR COMPOSURE. • THOSE AROUND YOU COULD BE • • • Colleagues The crowd The patient 122 79

MANAGEMENT USE PERSUASION OVER FORCE • BEHAVIORAL EMERGENCIES ARE POWER KEGS WAITING FOR A SPARK TO IGNITE THE EXPLOSION. • THE EXPLOSION CAN BE A • An attempt to restrain the patient • Angry friends or family becoming violent over what they perceive as inappropriate treatment 123 80

MANAGEMENT USE PERSUASION OVER FORCE • PERSUASION CAN BE. . • Negotiating with the patient so that they will come with you. • Never make promises you cannot keep • Never make a promise that could jeopardize your safety. 124 81

MANAGEMENT USE PERSUASION OVER FORCE • PERSUASION CAN BE. . • A show of force • Even crazy people know when they are beat. 125 82

MANAGEMENT USE PERSUASION OVER FORCE • WHEN ALL ELSE FAILS. . . • TAKE THE PATIENT DOWN. 126 83

MANAGEMENT • Do not forget the obvious such as hypoglycemia, hypoxia • Do not feed into the patients delusions. They will not believe you. After all it is their delusion and not yours. • Do not agitate the patient. This will spark the powder keg. 127 84

MANAGEMENT • Always assure a patent airway in a restrained patient. • Do not remove restraints until the patient is secure in the hospital • Don’t “borrow” handcuffs. If they are on the patient, the police officer show be there with them. 128 85

MANAGEMENT • Chemical Restraints • ADULT STANDING ORDERS • Haloperidol 5 mg IM; and/or • Lorazepam 2 mg IV/IO/IM; or • Midazolam 2 -6 mg IV/IO/IM/IN • NOTE: In patients >70 years of age, limit medication to half these doses. • PEDIATRIC STANDING ORDERS • Midazolam 0. 1 mg/kg IV/IO/IM/IN 129