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Psychiatric Patient

Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department (2017)

Scope of Application

This guideline is intended for physicians working in emergency departments.

Inclusion Criteria

This guideline applies to adult patients presenting to the emergency department with psychiatric symptoms. Critical question 4 includes patients with delirium.

Exclusion Criteria

This guideline is not intended to be used for pediatric patients. It is also not intended for patients with delirium in regard to critical questions 1, 2, and 3.

Critical Questions

  • In the alert adult patient presenting to the emergency department with acute psychiatric symptoms, should routine laboratory tests be used to identify contributory medical conditions (nonpsychiatric disorders)?
    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing.
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing.
  • In the adult patient with new-onset psychosis without focal neurologic deficit, should brain imaging be obtained acutely?
    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    Use individual assessment of risk factors to guide brain imaging in the emergency department for patients with new-onset psychosis without focal neurologic deficit. (Consensus recommendation)
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    Use individual assessment of risk factors to guide brain imaging in the emergency department for patients with new-onset psychosis without focal neurologic deficit. (Consensus recommendation)
  • In the adult patient presenting to the emergency department with suicidal ideation, can risk-assessment tools in the emergency department identify those who are safe for discharge?
    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    In patients presenting to the emergency department with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account.
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    In patients presenting to the emergency department with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account.
  • In the adult patient presenting to the emergency department with acute agitation, can ketamine be used safely and effectively?
    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    Ketamine is one option for immediate sedation of the severely agitated patient who may be violent or aggressive. (Consensus recommendation)
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    Ketamine is one option for immediate sedation of the severely agitated patient who may be violent or aggressive. (Consensus recommendation)

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Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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