Grand Rounds October 19, 2023

302 & 201, What Emergency Physicians Need to Know– Eric Eustice, DO

• 201: Voluntary admission
  • Only adult can sign for this
  • Minor considered 14 and under
• 302: involuntary
  • Threat to self, others, patient refusing to sign 201, severely mentally ill
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9:30-10) Mental Health Concerns – Guhan Rammohan, MD

How to work up a psychiatric patient…consider the following

• Point-of-care glucose
• CBC
• Chem 7
• LFTs
• ECG (for toxicology evaluation)
• ASA level
• Tylenol level
• Urine toxicology screen/Blood toxicology screen
• EtOH
• Urine pregnancy/beta-hCG (if female of childbearing age)
• Consider:
  • Ammonia (see Hepatic encephalopathy)
  • TSH (hypo or hyperthyroidism may mimic mental illness)
  • CXR (for Tb screen or rule-out delirium in older patient)
  • UA (for rule-out delirium in older patients)
  • Head CT (to rule-out ICH in patients with AMS)
  • Lumbar puncture (to rule-out meningitis or encephalitis)

General Ed management of psych

• Non-pharmacologic
  • Verbal de-escalation
  • Offer comforting items: blanket, meal, pillow, etc
  • Quiet room
  • Physical restraints (should administer medications if restraints used, as decreases restraint time)
• Pharmacologic: Goal is to calm patient without oversedation
  • No history of psychosis
    • Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
      • Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
    • Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg (PO/IM/SL) or ziprasidone 10-20mg IM
  • Known or suspected underlying psychotic illness
    • Continue treatment with previous antipsychotic or
    • PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
    • IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
    • (PO/IM/IV) Haloperidol 0.5-5mg +/- lorazepam 0.5-2mg
      • Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)

12-12:30) EM Case Presentation – John Bianco, MD

12:30-1:00) TRIAGE

• Toxicology:
  • Nicotine ingestions🡪 1mg/kg is toxic to children
    • Mimics the effects of ACH
• Radiology: Lisfranc Injuries
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  • MOI:a xial load on plantar flexed foot or severe twisting action
  • Disruption of Lisfranc ligament- consisting of dorsal ligament, interosseus ligament and plantar ligament-🡪 disruption of midfoot
  • What to look for on exam?
    • Pain and swelling in midfoot
    • Ecchymosis to plantar surface ( PATHOGNOMONIC)
  • Weight bearing xrays are super helpful
• Integument
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• Ancillary
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