Behavioral Emergencies

PediatricBehavioralEmergencies : 

Alameda County EMS PediatricBehavioralEmergencies Cynthia Frankel, RN Prehospital Care Coordinator Alameda County EMS

Objectives : 

Alameda County EMS Objectives Management strategies & challenges Management concepts Principles of medication treatment Case study

The Call . . . : 

Alameda County EMS The Call . . . You are dispatched to the home of a seven year old male. The child is violent, oppositional, defiant, hitting, kicking, and throwing objects. He is exploding with rage. He expressed a desire to die because living was “…just too hard!” The mother asks you to leave her son alone and not transport him to the hospital.

Initial Assessment : 

Alameda County EMS Initial Assessment Seven year old male child screaming “I want to die, I hate you…I am too much trouble…My head is exploding.” A-B-C’s A: Normal B: Hyperventilation C: Tachycardia

Current Medications : 

Alameda County EMS Current Medications Risperidone (Risperdal) .250 mg BID Depakote (divalproex sodium) 125 mg TID Periactin (Cyproheptadine) 4 mg BID Concerta (methylphenidate) 38 mg am dose

Past Medical History : 

Alameda County EMS Past Medical History Diagnoses - reported by mother Bipolar ADHD with excitability Obsessive compulsive Psychotic episodes Unstable on current medications Previous hospitalizations and suicide attempts Followed by child psychiatrist and psychologist Police have been called to home on numerous occasions

What do you do? : 

Alameda County EMS What do you do? Things to consider: Police assistance 5150 Restraints Base Physician Consult Transport vs. Refusal of Care

Definition : 

Alameda County EMS Definition Pediatric behavioral emergency exist when: disorder of thought or behavior is dangerous or disturbing to the child or to others behavior likely to deviate from social norm and interfere with child’s well-being or ability to function.

Behavioral Emergencies : 

Alameda County EMS Behavioral Emergencies True psychiatric emergencies in children are rare. do not always stem from mental illness are more likely to stem from situational problems may be due to other medical problems or injury

Situational Problems : 

Alameda County EMS Situational Problems Behavioral emergencies may be precipitated by stressful situations: Chronic abuse or neglect Normal emotional upheaval of adolescence Unplanned pregnancy Sudden traumatic event Emotional upheaval but not necessarily involve an emotional disorder

Injuries or Medical Conditions That Mimic Psychiatric Illness : 

Alameda County EMS Injuries or Medical Conditions That Mimic Psychiatric Illness Diabetic ketoacidosis Hypoglycemia Brain injury Meningitis Encephalitis Seizure disorders Hypoxia Toxic ingestions Altered mental status Hallucinations Delusions Incoherent speech Aggressive/aberrant behavior Certain medications

Don’t Be Fooled… : 

Alameda County EMS Don’t Be Fooled… Psychiatric disorders: Can present with the appearance of a medical problems Example: anxiety disorder with a panic attack hyperventilation, tachycardia, diaphoresis, chest pain suggesting a medical emergency. A child with a history of mental illness: May present situational or physical problem unrelated to the psychiatric history

Potential Diagnosis : 

Alameda County EMS Potential Diagnosis Mood Disorders Bi-Polar Disorder Autism Attention Deficit (Hyperactivity) Disorder ADD/ADHD Schizophrenia

Bipolar Disorder : 

Alameda County EMS Bipolar Disorder Also called manic-depressive Illness - aberrant behavior during a manic phase Can “rapid-cycle” through several moods. Under-diagnosed and under-treated in children - Often misdiagnosed 1 in 5 kids commit suicide. Most mental health professionals believe BP rarely occurs before adolescence

Autism : 

Alameda County EMS Autism Complex developmental disorder Evident in the first three years of life Difficulties in verbal and non-verbal communications, social interaction, leisure and play activities 80% of those affected are male.

ADD/ADHD : 

Alameda County EMS ADD/ADHD Hyperactive Inattentive Mixed Impairments: language restricted activities and interests Social skills

Schizophrenia : 

Alameda County EMS Schizophrenia Hallucinations A false perception having no relation to reality. May be visual, auditory, or olfactory. (Seeing, hearing smelling things that aren’t there.) Delusions A false belief inconsistent with the individual’s own knowledge and experience. Patient can not separate delusion from reality. (Delusions may cause him/her to hurt self or others.) Violent behavior

Pharmacology : 

Alameda County EMS Pharmacology Drugs used to treat BP: Cibalith-S, eskalith, lithane, lithobid (Lithium) Tegretol (carbamazepine) Depakote (divalproex) Side effects: Excessive sweating ? Headache Potential liver problems ? Fatigue Lethal at toxic levels ? Nausea

Pharmacology (cont.) : 

Alameda County EMS Pharmacology (cont.) Drugs used to treat schizophrenia: Standard antipsychotics: Thorazine (chlorpromazine) Haldol (haloperidol) Serentil (mesoridazine) Side effects: Weight gain • Fatigue Emotional blunting • Rigidity Tremor • Muscle spasm Restlessness • Tardive dyskinesia Side effects are from cumulative use

Pharmacology (cont.) : 

Alameda County EMS Pharmacology (cont.) Drugs used to treat schizophrenia (cont.): Atypical Antipsychotics (drug/side effects) Risperidone (risperdol) : no sedation or muscular side effects Quetiapine (seroquel): sedation, least likely to produce muscular side effects Olanzapine (zyprexa) : weight gain Clozapine (clozapine): most effective, most side effects

Pharmacology (cont.) : 

Alameda County EMS Pharmacology (cont.) Drugs Used to treat depression SSRIs: Prozac (Fluoxetine); Paxil (Paroxetine); Luvox (Fluvoxamine) Tricyclic AD: Imipramine (Tofranil); clomipramine (Anafranil); MAOIs: Seligiline (Anipryl) Hetercyclic AD: Serzone (Nefazodonr); Bupropion HCL (Wellbutrin) Miscellaneous: Effexor (Venlafaxine)

Treating Side Effects : 

Alameda County EMS Treating Side Effects Dystonic Reactions (#7231) Ingestion of phenothiazines Adminsiter diphenhydramine Tricyclic Antidepressant OD (#7220) Widened QRS Hypotension unresponsive to fluids Sodium Bicarb These are adult policies. May be used in kids >15 – otherwise requires base physician contact.

Handling a Behavioral Emergency : 

Alameda County EMS Handling a Behavioral Emergency Other EMS policies that may be helpful when dealing with a behavioral emergency: Psychiatric Evaluation (#8105) Refusal of Care (#8040) Restraints (#8060) Consent & Refusal Guidelines (#10003)

Handling a Behavioral Emergency (cont.) : 

Alameda County EMS Handling a Behavioral Emergency (cont.) Treat potentially life-threatening medical conditions, do not diagnose psychiatric disorders Avoid making judgments or subjective interpretations of the patient’s actions

Handling a Behavioral Emergency (cont.) : 

Alameda County EMS Handling a Behavioral Emergency (cont.) Look for suspicious injuries that indicate: Child abuse Self-mutilation Suicide attempt Evaluate suicide risk - factors increasing risk: Recent depression Recent loss of family or friend Financial setback Drug use Having a detailed plan

Handling a Behavioral Emergency (cont.) : 

Alameda County EMS Handling a Behavioral Emergency (cont.) Communicating with an emotionally disturbed child: Provide the right environment - approach the child in a calm, reassuring manner Limit number of people around patient; isolate the patient if necessary Limit interruptions Limit physical touch Engage in active listening Strive to gain the child’s confidence

Back to our case… : 

Alameda County EMS Back to our case… With the information you have learned today What is your assessment? How would handle the situation? What options are available to you?

In Conclusion : 

Alameda County EMS In Conclusion Embrace these Families Many psychiatric illnesses are new and evolving Each child responds differently to psychiatric medications Notify the child’s mental health professional On-going assessment and safety considerations