Pediatric emergency medicine trisk 1040

children may also have concomitant medical problems and, in fact, are at greater risk for presenting with emergent medical conditions such as injuries and ingestions than are nonpsychiatrically ill children A thorough medical history, including current medication and possible ingestions, followed by a complete physical examination, including a complete neurologic examination is all that is required for the majority of patients There is no “standard” set of laboratory evaluations that must be obtained to “clear” a psychiatric patient Patients with new onset of or acute change in psychiatric symptoms, especially psychosis or alterations in mental status, must be carefully evaluated for possible underlying medical conditions These patients may require additional laboratory evaluation or subspecialist consultation In addition, some psychiatric facilities may request or require baseline laboratory data before accepting a transfer Toxicologic screens and pregnancy tests in postpubertal teens are the most frequently obtained laboratory tests Table 126.2 lists laboratory evaluations that may be considered for psychiatric patients TABLE 126.2 SCREENING TESTS FOR MEDICAL ILLNESS Complete blood cell count with differential Complete blood chemistries (including measurements of electrolytes, glucose, calcium, and magnesium levels and tests of hepatic and renal function) Thyroid function tests Pregnancy test Urinalysis Urine and serum toxicology screen EKG Plasma levels of any drugs being taken, if appropriate Neuroimaging (if clinically indicated) 10 Lumbar puncture (if clinically indicated) EKG, electrocardiogram; CT, computed tomography Adapted from Sadock BJ, Sadock VA, eds Kaplan & Sadock’s Synopsis of Psychiatry 9th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2003:24 TABLE 126.3 CHILDHOOD/ADOLESCENT PSYCHIATRIC EMERGENCIES: CHILD MENTAL STATUS EXAMINATION Orientation Appearance Memory Cognition Behavior Speech Mood and affect Thought process Thought content (including suicidal ideation, homicidal ideation, obsessions, delusions, hallucinations) Insight and judgment Mental Status of the Child Evaluation of the child’s mental status takes place throughout the entire ED visit The mental status examination provides a psychological profile of the child and contributes to the assessment of psychiatric diagnoses Frequently much of the relevant data often emerge during the history, physical examination, and interactions with the child and family members The emergency physician should have a systematic and thorough understanding of the mental status examination and should follow up any areas of concern with more specific questions Table 126.3 lists the major categories of the mental status examination, with a focus on the aspects most relevant to emergency psychiatric assessment Family Evaluation The mental status of the family can be assessed while observing the presentation of the history and the interactions of caregivers with the patient during the ED visit The presentation of caregivers should be coherent and logical and should follow a temporal sequence Family members under the influence of drugs or alcohol may not be fully alert and oriented Depressed parents may appear withdrawn and downcast and may be so preoccupied with their depression that they not focus effectively on the child’s problem or may blame the child for their own problems Families that not present with organized mental and social functioning may have serious difficulties resolving crises ( Table 126.4 ) The goal of a family evaluation for childhood psychiatric emergencies is to determine the methods they use to help the child when distressed, how well these work, and gauge the willingness to try new strategies to help with the current crisis When the physician approaches parents as partners, the likelihood of an effective collaboration between parents and medical staff is maximized Using Social Support Some families come to the ED feeling isolated, overwhelmed, and exhausted Often, such families have not used all the family and community resources available to them Effective crisis intervention for psychiatric emergencies involves not only emergency treatment but also effective disposition planning for the family The ED staff should determine what other family members and community resources are available to the family TABLE 126.4 CHILDHOOD/ADOLESCENT PSYCHIATRIC EMERGENCIES: FAMILY ASSESSMENT Signs of competence and strength Level of concern Verbal communication Problem-solving ability Relationships Parents and child Parents or caregivers Parents and physician Danger signs with parents/caregivers Psychosis Intoxication/drug abuse Depression Violence History of abuse (physical, emotional, sexual) and/or neglect Resources for ED Clinicians The American College of Emergency Physicians (ACEP), the American Academy of Child and Adolescent Psychiatry (AACAP), and the Substance Abuse Mental Health Services Administration (SAMHSA) have a number of online resources which may assist ED clinicians, including a National Helpline (https://www.samhsa.gov/find-help/national-helpline ), Treatment Locators (https://findtreatment.samhsa.gov/ , https://www.samhsa.gov/esmitreatment-locator ), and substance use disorders (https://dpt2.samhsa.gov/treatment/ , https://acep.org/administration/quality/equal/e-qual-opioid-initiative/e-qualopioid-toolkit/ , https://www.aacap.org/aacap/families_and_youth/resource_centers/Substanc e_Use_Resource_Center/Home.aspx )  ... during the history, physical examination, and interactions with the child and family members The emergency physician should have a systematic and thorough understanding of the mental status examination... major categories of the mental status examination, with a focus on the aspects most relevant to emergency psychiatric assessment Family Evaluation The mental status of the family can be assessed... resources available to them Effective crisis intervention for psychiatric emergencies involves not only emergency treatment but also effective disposition planning for the family The ED staff should determine