Emerg Med Clin North Am
· 2024 Feb · PMID 37977753
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Substance use disorders (SUDs) present a challenge in the emergency department (ED) setting. This article provides an overview of SUDs, their clinical assessment, legal considerations in drug testing, diagnosis, and trea...Substance use disorders (SUDs) present a challenge in the emergency department (ED) setting. This article provides an overview of SUDs, their clinical assessment, legal considerations in drug testing, diagnosis, and treatment approaches. SUDs are prevalent and coexist with mental health disorders, necessitating comprehensive evaluation and management. Clinical assessment involves screening tools, substance use history, and identification of comorbidities. Diagnosis relies on a thorough evaluation of substance abuse patterns and associated medical conditions. Treatment approaches encompass a multidisciplinary approach, incorporating counseling, medications, and social support. Effective management of SUDs in the ED requires a comprehensive understanding of these complex disorders.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977752
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Hyperactive delirium with severe agitation is a clinical syndrome of altered mental status, psychomotor agitation, and a hyperadrenergic state. The underlying pathophysiology is variable and often results from sympathomi...Hyperactive delirium with severe agitation is a clinical syndrome of altered mental status, psychomotor agitation, and a hyperadrenergic state. The underlying pathophysiology is variable and often results from sympathomimetic abuse, psychiatric disease, sedative-hypnotic withdrawal, and metabolic derangement. Patients can go from a combative state to periarrest with little warning. Safety of the patient and of the medical providers is paramount and the emergency department should be prepared to manage these patients with adequate staffing, restraints, and pharmacologic sedatives. Treatment with benzodiazepines, antipsychotics, or ketamine is recommended, followed by airway protection, supportive measures, and cooling of hyperthermia.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977751
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Patients frequently present to the emergency department (ED) with acute suicidal and homicidal thoughts. These patients require timely evaluation, with determination of disposition by either voluntary or involuntary hosp...Patients frequently present to the emergency department (ED) with acute suicidal and homicidal thoughts. These patients require timely evaluation, with determination of disposition by either voluntary or involuntary hospitalization or discharge with appropriate outpatient follow-up. Safety concerns should be prioritized for patients as well as ED staff. Patient dignity and autonomy should be respected throughout the process.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977750
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Individual rights can be limited in the context of psychiatric emergencies. The emergency physician should be familiar with state laws pertaining to involuntary holds. Physicians are equipped to perform a medical screeni...Individual rights can be limited in the context of psychiatric emergencies. The emergency physician should be familiar with state laws pertaining to involuntary holds. Physicians are equipped to perform a medical screening examination, address mental health concerns, and lead efforts to de-escalate agitation. The physician should conduct a thorough assessment and distinguish between malingering and mental health decompensation, when appropriate.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977749
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Malingering is the intentional production of false or grossly exaggerated symptoms motivated by internal and external incentives. The true incidence of malingering in the emergency department is unknown because of the di...Malingering is the intentional production of false or grossly exaggerated symptoms motivated by internal and external incentives. The true incidence of malingering in the emergency department is unknown because of the difficulty of identifying whether patients are fabricating their symptoms. Malingering is considered a diagnosis of exclusion; a differential diagnosis framework is described to guide emergency physicians. Several case studies are presented and analyzed from a medical ethics perspective. Practical recommendations include use of the NEAL (neutral, empathetic, and avoid labeling) strategy when caring for patients suspected of malingering.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977748
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Anorexia nervosa (AN) and bulimia nervosa (BN) are easily missed in the emergency department, because patients may present with either low, normal, or increased BMI. Careful examination for signs of purging and excessive...Anorexia nervosa (AN) and bulimia nervosa (BN) are easily missed in the emergency department, because patients may present with either low, normal, or increased BMI. Careful examination for signs of purging and excessive use of laxatives and promotility agents is important. Careful examination for and documentation of dental erosions, posterior oropharyngeal bruising, Russel's sign, and salivary and parotid gland inflammation are clues to the purging behavior. Treatment for AN should include cognitive behavioral therapy with concomitant efforts to treat any psychiatric comorbidities, whereas BN and BED have been successfully treated with fluoxetine and lisdexamfetamine, respectively.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977747
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Pediatric psychiatric emergencies account for 15% of emergency department visits and are on the rise. Psychiatric diagnoses in the pediatric population are difficult to make, due to their variable presentation, but early...Pediatric psychiatric emergencies account for 15% of emergency department visits and are on the rise. Psychiatric diagnoses in the pediatric population are difficult to make, due to their variable presentation, but early diagnosis and treatment improve clinical outcome. Medical reasons for the patient's presentation should be explored. Both physical and emotional safety must be ensured. A multidisciplinary approach, utilizing local primary care and psychiatric resources, is recommended.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977746
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Geriatric patients, those 65 years of age and older, often experience psychiatric symptoms or changes in mentation as a manifestation of an organic illness. It is crucial to recognize and treat delirium in these patients...Geriatric patients, those 65 years of age and older, often experience psychiatric symptoms or changes in mentation as a manifestation of an organic illness. It is crucial to recognize and treat delirium in these patients as it is often under-recognized and associated with significant morbidity. Iatrogenic causes of altered mentation or delirium due to medication adverse reactions are common. Treatment of the underlying cause, creating an environment conducive to orientation, and minimizing agitation and discomfort are first-line interventions. Antipsychotics are first-line pharmacologic interventions if needed to preserve patient safety.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977745
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The acutely agitated patient should be managed in a step-wise fashion, beginning with non-coercive de-escalation strategies and moving on to pharmacologic interventions and physical restraints as necessary. Face-to-face...The acutely agitated patient should be managed in a step-wise fashion, beginning with non-coercive de-escalation strategies and moving on to pharmacologic interventions and physical restraints as necessary. Face-to-face examination, monitoring, and documentation by the physician are essential. The emergency physician should be familiar with multiple pharmaceutical options, tailored to the individual patient. Use of ketamine, benzodiazepines and antipsychotics should be considered. Patient autonomy, safety, and medical well-being are paramount.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977744
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Caring for patients with personality disorders and traits presents unique challenges for physicians and other providers. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, recognizes 10 personality...Caring for patients with personality disorders and traits presents unique challenges for physicians and other providers. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, recognizes 10 personality disorders, which are organized into 3 clusters (A, B, and C) based on shared diagnostic features. Personality disorders or traits create difficulty in clinical and interpersonal interactions, promoting missed diagnosis or underdiagnosis, nonadherence to medical recommendations, or other dangerous outcomes. It is important to recognize patients with potential personality disorders and understand strategies to achieve optimal patient interactions and best possible medical outcomes.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977743
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Affective disorders affect the way that people think and feel and are classified into unipolar disorders and bipolar disorders. Bipolar disorders represent a spectrum of these chronic mental health illnesses. Patients wi...Affective disorders affect the way that people think and feel and are classified into unipolar disorders and bipolar disorders. Bipolar disorders represent a spectrum of these chronic mental health illnesses. Patients with bipolar disorder have high recurrence of acute symptoms, and on average spend 20% of their life in exacerbations characterized by mania, depression, or psychosis. Given the increased morbidity and mortality associated with bipolar disorders, it is imperative that the emergency physician remain vigilant when these patients seek emergency care.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977742
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Depressive disorders encompass a spectrum of diagnoses and are more common in women and transgender individuals. Diagnosis involves thorough history-taking and exclusion of underlying medical disorders. The emergency phy...Depressive disorders encompass a spectrum of diagnoses and are more common in women and transgender individuals. Diagnosis involves thorough history-taking and exclusion of underlying medical disorders. The emergency physician should assess the risk of self-harm and consider environmental and social factors prior to disposition.
Emerg Med Clin North Am
· 2024 Feb · PMID 37977741
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A quality clinical interview helps establish a good collaborative relationship with the patient. This is especially important when emergency physicians conduct a psychiatric interview. Familiarity with interview techniqu...A quality clinical interview helps establish a good collaborative relationship with the patient. This is especially important when emergency physicians conduct a psychiatric interview. Familiarity with interview techniques, empathic listening, and observation of nonverbal cues, behavior, and appearance enhance diagnostic excellence.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758429
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Respiratory acid-base disorders are often not thought of as frequently as their metabolic cousins, which occur more frequently in the emergency department. Although most respiratory and acid-base disturbances are driven...Respiratory acid-base disorders are often not thought of as frequently as their metabolic cousins, which occur more frequently in the emergency department. Although most respiratory and acid-base disturbances are driven by lung pathology, central nervous system and other organ systems can and do play a role as well. Although managing the airway and appropriate mechanical ventilation may be necessary, it is akin to placing a band-aid on a large wound. It is crucial for the emergency clinician to discover the etiology of the disturbance as management depends on treating the underlying etiology to prevent worsening acid-base status.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758428
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Metabolic acid-base disturbances are frequently encountered in the emergency department, and many of these patients are critically ill. In the evaluation of patients with these maladies, it is important for the emergency...Metabolic acid-base disturbances are frequently encountered in the emergency department, and many of these patients are critically ill. In the evaluation of patients with these maladies, it is important for the emergency clinician to determine the cause, which can usually be elicited from a thorough history and physical examination. There are several mnemonics that can be used to form an appropriate list of potential causes. Most of the time, the management of these patients requires no specific treatment of the acid-base status but, rather, requires treatment of the underlying disorder that is causing the acid-base disturbance.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758427
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This review will discuss the importance and homeostasis of calcium and magnesium in the human body, as well as the implications and treatment of disordered calcium and magnesium. With calcium and magnesium often consider...This review will discuss the importance and homeostasis of calcium and magnesium in the human body, as well as the implications and treatment of disordered calcium and magnesium. With calcium and magnesium often considered to be the "forgotten cations" in medicine, it is our hope that this review will lead providers to evaluate for and effectively manage these electrolyte disorders in the emergency department.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758426
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Endocrine diseases are rare and can present very subtly in the neonatal period. Most are diagnosed using newborn screening in the United States; however, some infants may present with false negatives or more subtle findi...Endocrine diseases are rare and can present very subtly in the neonatal period. Most are diagnosed using newborn screening in the United States; however, some infants may present with false negatives or more subtle findings. Endocrine etiologies should be considered during the management of critically ill infants. This article will give an overview of endocrine emergencies encountered in the neonatal period, including disorders of glucose metabolism, thyroid disorders, adrenal disorders, and pituitary disorders.
Emerg Med Clin North Am
· 2023 Nov · PMID 37758425
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Patients with alcohol use disorders are commonly identified and managed in the emergency department. Although the alcohol-intoxicated patient has a high risk for significant injury and diseases, the majority will be allo...Patients with alcohol use disorders are commonly identified and managed in the emergency department. Although the alcohol-intoxicated patient has a high risk for significant injury and diseases, the majority will be allowed to sober in the emergency department and can be discharged without incident. However, there are metabolic derangements in these patients, such as alcoholic ketoacidosis, Wernicke-Korsakoff, and potomania that very commonly present similar to intoxication and can be misdiagnosed by emergency clinicians.