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Home My WebLink Aboutbehavioral-emergenciesAlameda County EMS Pediatric Behavioral Emergencies Cynthia Frankel, RN Prehospital Care Coordinator Alameda County EMS Alameda County EMS Objectives Management strategies & challenges Management concepts Principles of medication treatment Case study 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. 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 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 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 Alameda County EMS What do you do? Things to consider: Police assistance 5150 Restraints Base Physician Consult Transport vs. Refusal of Care 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. 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 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 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 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 Alameda County EMS Potential Diagnosis Mood Disorders Bi-Polar Disorder Autism Attention Deficit (Hyperactivity) Disorder ADD/ADHD Schizophrenia 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 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. Alameda County EMS ADD/ADHD Hyperactive Inattentive Mixed Impairments: language restricted activities and interests Social skills 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 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 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 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 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) 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. 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) 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 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 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 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? 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