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Psychiatric Patient (Adult)

Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department (January 2006)

Complete Clinical Policy on Psychiatric Patient  (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based emergency departments (EDs).

Inclusion Criteria. This guideline is intended for adult patients presenting to the ED with psychiatric symptoms.

Exclusion Criteria. This guideline, with the exception of question 4, is not intended for patients with delirium or abnormal vital signs, altered cognition, or abnormal physical examination. Pediatric patients are also excluded.

Critical Questions

1. What testing is necessary in order to determine medical stability in alert, cooperative patients with normal vital signs, a noncontributory history and physical examination, and psychiatric symptoms?

  • Level A recommendations. None specified.


  • Level B recommendations. In adult ED patients with primary psychiatric complaints, diagnostic evaluation should be directed by the history and physical examination. Routine laboratory testing of all patients is of very low yield and need not be performed as part of the ED assessment.


  • Level C recommendations. None specified.

2. Do the results of a urine drug screen for drugs of abuse affect management in alert, cooperative patients with normal vital signs, a noncontributory history and physical examination, and a psychiatric complaint?

  • Level A recommendations. None specified.


  • Level B recommendations. None specified.


  • Level C recommendations. (1) Routine urine toxicologic screens for drugs of abuse in alert, awake, cooperative patients do not affect ED management and need not be performed as part of the ED assessment.
    (2) Urine toxicologic screens for drugs of abuse obtained in the ED for the use of the receiving psychiatric facility or service should not delay patient evaluation or transfer.

3. Does an elevated alcohol level preclude the initiation of a psychiatric evaluation in alert, cooperative patients with normal vital signs and a noncontributory history and physical examination?

  • Level A recommendations. None specified. 


      
  • Level B recommendations. None specified.


  • Level C recommendations. (1) The patient's cognitive abilities, rather than a specific blood alcohol level, should be the basis on which clinicians begin the psychiatric assessment.
    (2) Consider using a period of observation to determine if psychiatric symptoms resolve as the episode of intoxication resolves. 

      

4. What is the most effective pharmacologic treatment for the acutely agitated patient in the ED?

  • Level A recommendations. None specified.


  • Level B recommendations. (1) Use a benzodiazepine (lorazepam or midazolam) or a conventional antipsychotic (droperidol* or haloperidol) as effective monotherapy for the initial drug treatment of the acutely agitated undifferentiated patient in the ED.
    (2) If rapid sedation is required, consider droperidol* instead of haloperidol.
    (3) Use an antipsychotic (typical or atypical) as effective monotherapy for both management of agitation and initial drug therapy for the patient with known psychiatric illness for which antipsychotics are indicated.
    (4) Use a combination of an oral benzodiazepine (lorazepam) and an oral antipsychotic (risperidone) for agitated but cooperative patients.

    *Refer to the discussion of droperidol in the text.


  • Level C recommendations. The combination of a parenteral benzodiazepine and haloperidol may produce more rapid sedation than monotherapy in the acutely agitated psychiatric patient in the ED.

Purpose of ACEP's Clinical Policies

Clinical Findings and Strength of Recommendations