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Open Access Publications from the University of California

Volume 13, Issue 1, 2012

Behavioral Emergencies: Best Practices in Evaluation and Treatment of Agitation

Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup

Numerous medical and psychiatric conditions can cause agitation, some of these causes are life threatening. It is important to be able to differentiate between medical and non-medical causes of agitation so that patients can receive appropriate and timely treatment. This article aims to educate all clinicians in non-medical settings, such as mental health clinics, and medical settings on the differing levels of severity in agitation, basic triage, use of de-escalation, and factors, symptoms, and signs in determining whether a medical etiology is likely. Lastly, this article focuses on the medical workup of agitation when a medical etiology is suspected or when etiology is unclear. [West J Emerg Med. 2012;13(1):3–10.]

Psychiatric Evaluation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychiatric Evaluation Workgroup

It is difficult to fully assess an agitated patient, and the complete psychiatric evaluation usually cannot be completed until the patient is calm enough to participate in a psychiatric interview. Nonetheless, emergency clinicians must perform an initial mental status screening to begin this process as soon as the agitated patient presents to an emergency service. For this reason, the psychiatric evaluation of the agitated patient can be thought of as a two-step process. First a brief evaluation must be aimed at determining the most likely cause of agitation, so as to guide preliminary interventions to calm the patient. Once the patient is calmed, more extensive psychiatric assessment can be completed. The goal of the emergency assessment of the psychiatric patient is not necessarily to obtain a definitive diagnosis. Rather, ascertaining a differential diagnosis, determining safety, and developing an appropriate treatment and disposition plan are the goals of the assessment. This article will summarize what components of the psychiatric assessment can and should be done at the time the agitated patient presents. The complete psychiatric evaluation of the patient whose agitation has been treated successfully is beyond the scope of this paper and Project BETA, but will be outlined briefly to give the reader an understanding of what a full psychiatric assessment would entail. Other issues related to the assessment of the agitated patient in the emergency setting will also be discussed. [West J Emerg Med. 2012;13(1):11–16.]

Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup

Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. In the new paradigm, a 3-step approach is used. First, the patient is verbally engaged; then a collaborative relationship is established; and, finally, the patient is verbally deescalated out of the agitated state. Verbal de-escalation is usually the key to engaging the patient and helping him become an active partner in his evaluation and treatment; although, we also recognize that in some cases nonverbal approaches, such as voluntary medication and environment planning, are also important. When working with an agitated patient, there are 4 main objectives: (1) ensure the safety of the patient, staff, and others in the area; (2) help the patient manage his emotions and distress and maintain or regain control of his behavior; (3) avoid the use of restraint when at all possible; and (4) avoid coercive interventions that escalate agitation. The authors detail the proper foundations for appropriate training for de-escalation and provide intervention guidelines, using the ‘‘10 domains of deescalation.’’ [West J Emerg Med. 2012;13(1):17–25.]

The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup

Agitation is common in the medical and psychiatric emergency department, and appropriate management of agitation is a core competency for emergency clinicians. In this article, the authors review the use of a variety of first-generation antipsychotic drugs, second-generation antipsychotic agents, and benzodiazepines for treatment of acute agitation, and propose specific guidelines for treatment of agitation associated with a variety of conditions, including acute intoxication, psychiatric illness, delirium, and multifocal or idiopathic causes. Pharmacologic treatment of agitation should be based on an assessment of the most likely cause for the agitation. If agitation results from a medical condition or delirium, clinicians should first attempt to treat this underlying cause instead of simply medicating with antipsychotics or benzodiazepines. [West J Emerg Med. 2012;13(1):26–34.]

Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup

Issues surrounding reduction and/or elimination of episodes of seclusion and restraint for patients with behavioral problems in crisis clinics, emergency departments, inpatient psychiatric units and specialized psychiatric emergency services continue to be an area of concern and debate among mental health clinicians. An important underlying principle of Project BETA is non-coercive de-escalation as the intervention of choice in the management of acute agitation and threatening behavior.

In this paper, the authors discuss several aspects of seclusion and restraint, including review of CMS guidelines regulating their use in medical behavioral settings, negative consequences of this intervention to patients and staff and a review of quality improvement and risk management strategies that have been effective in decreasing its use in various treatment settings. An algorithm designed to help the clinician determine when seclusion or restraint is most appropriate is introduced. The authors conclude that the specialized psychiatric emergency services and emergency departments, because of their treatment of primarily acute patients, may not be able to entirely eliminate the use of seclusion and restraint events, but these programs can adopt strategies to reduce the utilization rate of these interventions. [West J Emerg Med. 2012;13(1):35–40.]

Behavioral Emergencies

Evaluation of an Emergency Department Educational Campaign for Recognition of Suicidal Patients

Introduction: To evaluate the impact of a simple emergency department (ED)–based educational intervention designed to assist ED providers in detecting occult suicidal behavior in patients who present with complaints that are not related to behavioral health.Methods: Staff from 5 ED sites participated in the study. Four ED staff members were exposed to a poster and clinical guide for the recognition and management of suicidal patients. Staff members in 1 ED were not exposed to training material and served as a comparator group.Results: At baseline, only 36% of providers reported that they had sufficient training in how to assess level of suicide risk in patients. Greater than two thirds of providers agreed that additional training would be helpful in assessing the level of patient suicide risk. More than half of respondents who were exposed to the intervention (51.6%) endorsed increased knowledge of suicide risk during the study period, while 41% indicated that the intervention resulted in improved skills in managing suicidal patients.Conclusion: This brief, free intervention appeared to have a beneficial impact on providers’ perceptions of how well suicidality was recognized and managed in the ED. [West J Emerg Med.2012;13(1):41–50.]

Impact of the Mental Health Care Delivery System on California Emergency Departments

Introduction: This is an observational study of emergency departments (ED) in California to identify factors related to the magnitude of ED utilization by patients with mental health needs.Methods: In 2010, an online survey was administered to ED directors in California querying them about factors related to the evaluation, timeliness to appropriate psychiatric treatment, and disposition of patients presenting to EDs with psychiatric complaints.Results: One hundred twenty-three ED directors from 42 of California’s 58 counties responded to the survey. The mean number of hours it took for psychiatric evaluations to be completed in the ED, from the time referral was placed to completed evaluation, was 5.97 hours (95% confidence interval [CI], 4.82–7.13). The average wait time for adult patients with a primary psychiatric diagnosis in the ED, once the decision to admit was made until placement into an inpatient psychiatric bed or transfer to an appropriate level of care, was 10.05 hours (95% CI, 8.69–11.52). The average wait time for pediatric patients with a primary psychiatric diagnosis was 12.97 hours (95% CI, 11.16–14.77). The most common reason reported for extended ED stays for this patient population was lack of inpatient psychiatric beds.Conclusion: The extraordinary wait times for patients with mental illness in the ED, as well as the lack of resources available to EDs for effectively treating and appropriately placing these patients, indicate the existence of a mental health system in California that prevents patients in acute need of psychiatric treatment from getting it at the right time, in the right place. [West J Emerg Med. 2012;13(1):51–56.]


Life in the inner city

[West J Emerg Med. 2012;13(1):57.]


Dose Dependent Response to Cyclodextrin Infusion in a Rat Model of Verapamil Toxicity

Introduction: Sulfobutylether-b-cyclodextrin (SBE-CD) is a pharmaceutical excipient known to bind verapamil. Following intravenous administration, clearance of SBE-CD approximates glomerular filtration rate. We hypothesized that infusion of SBE-CD would increase time to asystole in a rat model of verapamil toxicity in a dose-dependent manner. The objective was to demonstrate the effect of a range of SBE-CD concentrations in a rat model of verapamil toxicity. Methods: Twenty-five Wistar rats were allocated to control or 1 of 4 intervention groups. All received ketamine and diazepam anesthesia followed by verapamil infusion 32 mg/kg/h. The verapamil infusion for the intervention groups was premixed with SBE-CD in a 1:1, 1:2, 1:4, or 1:8 molar ratio (verapamil to SBE-CD). The control group infusion did not contain SBE-CD. Additional saline or water was added to the infusion so that the total volume infused was the same across groups, and the osmolality was maintained as close to physiologic as possible. Heart rate, respiratory rate, and temperature were monitored. The primary endpoint was time to asystole.Results: Verapamil coinfused with SBE-CD in a molar ratio of 1:4 resulted in prolonged time to asystole compared to control (21.2 minutes vs 17.6 minutes, P , 0.05). There were no differences in time to asystole between control and any other intervention group. There was no significant difference in time to apnea between control and any intervention group. We assessed the effect of a range of SBE-CD concentrations and identified 1 concentration that prolonged time to asystole. Mechanismsthat may explain this effect include optimal volume expansion with a hyperosmolar cyclodextrin containing solution, complexation of verapamil within the hydrophobic cyclodextrin pore, and/or complexation within micelle-like aggregates of cyclodextrin. However, mechanistic explanations for the observed findings are speculative at this point. Conclusion: The 1:4 verapamil to SBE-CD concentration was modestly effective with SBE-CD concentrations above and below this range demonstrating nonstatistically significant improvements in time to asystole. [West J Emerg Med. 2012;13(1):63–67.]

The Role for Coagulation Markers in Mild Snakebite Envenomations

Introduction: The majority of patients seeking medical treatment for snakebites do not suffer from severe envenomation. However, no guidelines exist for ordering coagulation markers in patients with minimal or moderate envenomation, nor in those who do not receive antivenom. In this study, we sought to determine whether it was possible to limit the practice of ordering coagulation studies to those patients suffering severe envenomation, rattlesnake envenomation, or both.Methods: A retrospective chart review was performed on all cases of crotalid snakebite presenting to an adult emergency department (ED) from April 1998 to June 2006. Each chart was abstracted for patient’s age, gender, type of snake (if known), severity of envenomation at initial presentation, coagulation test results, whether antivenom was administered, and whether the patient was admitted.Results: Over an approximately 8-year period, 131 snakebite cases presented that met the inclusion criteria, of which 35 (26.7%) had some type of coagulation marker abnormality. Limiting coagulation testing to patients suffering severe envenomation or rattlesnake envenomation would have resulted in failure to identify 89% or 77%, respectively, of the 35 patients who were found to have at least 1 abnormal coagulation marker.

Conclusion: Our study failed to identify a subset of patients that could be defined as low risk or for whom coagulation marker testing could be foregone. This study suggests that coagulation tests should be routinely performed on all patients presenting to the ED with complaints of envenomation by copperheads, moccasins, or rattlesnakes. Further clarification of when coagulation markers are indicated may require a prospective study that standardizes snake identification and the timing of coagulation marker testing. [West J Emerg Med. 2012;13(1):68–74.]

Massive Atropine Eye Drop Ingestion Treated with High-Dose Physostigmine to Avoid Intubation

Case: A 34-year-old male presented after ingesting 150 mg of atropine. He had altered mental status, sinus tachycardia, dry mucosa, flushed skin, and hyperthermia. Sequential doses of physostigmine, totaling 14 mg, were successful in reversing antimuscarinic toxicity and prevented the need to perform airway control with endotracheal intubation. At completion of treatment, heart rate and mental status had improved, and intubation was never performed.

Discussion: Atropine causes anticholinergic toxicity; physostigmine reverses this by inhibiting acetylcholinesterase. Atropine eye drop ingestions are rare. The 14 mg of physostigmine administered is much higher than typical dosing. It is likely the physostigmine prevented intubation. Atropine eye drops can be dangerous, and physostigmine should be considered in treatment. [West J Emerg Med. 2012;13(1):77–79.]


Aortocaval Fistula

[West J Emerg Med. 2012;13(1):90–91.]

Recognizing Infective Endocarditis in the Emergency Department

A 52-year-old Caucasian male presented to the emergency department complaining of nontraumatic painful swelling and redness of the distal left fourth finger for 2 days, associated with malaise and subjective fever. The patient denied medical history, drugs, tobacco, or alcohol use. [West J Emerg Med. 2012;13(1):92–93.]


Delayed Presentation of Sigmoid Volvulus in a Young Woman

Volvulus is an unusual condition in Western countries, generally isolated to elderly patients with multiple comorbidities. This report describes an unusual case of a very large gangrenous sigmoid volvulus in a young, otherwise healthy 25-year-old female. A review of the diagnosis and management is subsequently described. Without a consideration of the atypical demographics for sigmoid volvulus, the case illustrates the potential morbidity due to a delayed diagnosis. Early identification and management are crucial in treating sigmoid volvulus before the appearance of gangrene and necrosis, thereby avoiding further complications and associated mortality. [West J Emerg Med. 2012; 13(1):100–102.]

Right-Sided Sigmoid Diverticular Perforation

Diverticulosis is a common disorder among geriatric patients, of whom 10% to 25% go on to develop diverticulitis. Known complications of diverticulitis include formation of phlegmon, fistula, bowel obstruction, bleeding, perforation, and colonic abscess. A less common complication is perforation with formation of an extra-abdominal necrotizing abscess. This case is a report of an 83-year-old female who presented to the emergency department with a necrotizing abdominal wall abscess secondary to right-sided diverticular microperforation. [West J Emerg Med. 2012;13(1):103–105.]


Diplopia from Subacute Bilateral Subdural Hematoma after Spinal Anesthesia

Subdural hematoma (SDH) is a rare, but life-threatening complication of spinal anesthesia. Subdural hematoma resulting from this procedure could present with vague symptoms such as chronic headache and could easily be missed. Chronic headache is one of the symptoms of chronic SDH in postpartum women. Diplopia as the presenting complaint in SDH secondary to peripartum spinal anesthesia has not, to our knowledge, been previously reported. Here, we report a case of diplopia secondary to postpartum subacute bilateral SDHs with transtentorial herniation after spinal anesthesiain a healthy primagravid 25-year-old woman. SDH can expand gradually and the initial symptoms might be subtle as in our case, despite critically high intracranial pressure. [West J Emerg Med. 2012;13(1):108–110.]

Benign Nuchal Rigidity: The Emergency Department Evaluation of Acute Prevertebral Calcific Tendonitis

Acute prevertebral calcific tendonitis (APCT) is a rare condition, the exact incidence of which isunknown. It is of particular interest to the emergency physician owing to the other potentiallydevastating conditions in the differential diagnosis of neck stiffness and/or odynophagia (includingretropharyngeal abscess, infectious spondylitis, and meningitis.) In contrast, APCT has a benignclinical course and can be easily managed in the emergency department. We will present a case ofAPCT, followed by a brief discussion of the disease and current literature. [West J Emerg Med.2012;13(1):114–116.]


Tension Gastrothorax in a Child Presenting with Abdominal Pain

A 4-year-old girl was brought to our hospital by her parents because of abdominal pain. She hadsuffered minor trauma after rolling from her standard-height bed 2 days prior. Vital signs wereappropriate for age. Physical examination was remarkable for decreased breath sounds to the left sideof the chest. A chest radiograph (Figure) demonstrated a large gas-filled structure in the left side of thechest with mediastinal shift. [West J Emerg Med. 2012;13(1):117–118.]

Kohler's disease

We present a pediatric case report of foot pain due to Kohler’s disease. [West J Emerg Med. 2012;13(1):119–120.


Unilateral Internuclear Ophthalmoplegia after Minor Head Injur

Internuclear ophthalmoplegia is a rare condition caused by injury to the medial longitudinal fasciculus inthe brainstem. It usually occurs in conditions such as stroke or multiple sclerosis and is extremely rareafter head injury. We report a case of unilateral internuclear ophthalmoplegia, which occurred after aminor head injury in a young male. His only symptoms were headache and diplopia. He was treatedconservatively, and his symptoms settled after 3 months. [West J Emerg Med. 2012;13(1):123–124.]

Clinical Practice


Erosion of Embolization Coils into the Renal Collecting System Mimicking Stone

Urinary tract interventions can lead to multiple complications in the renal collecting system, includingretained foreign bodies from endourologic or percutaneous procedures, such as stents, nephrostomytubes, and others. We report a case of very delayed erosion of embolization coils migrating into therenal pelvis, acting as a nidus for stone formation, causing mild obstruction and finally leading to grosshematuria roughly 18 years post transarterial embolization. History is significant for a remoteunsuccessful endopyelotomy attempt that required an urgent embolization. [West J Emerg Med.2012;13(1):127–130.]

Testicular Compromise due to Inguinal Hernia

A 34-year-old male presented to the emergency department with a 3-hour complaint of pain in the rightlower quadrant and right testicle. He stated that his pain began suddenly while standing at work. Onphysical examination, he had a small, firm, unreducible bulge in his right inguinal canal and an enlargedright scrotum. The patient was placed in trendelenburg position; intravenous fentanyl, valium, anddilaudid were administered; and surgery consult was obtained. A testicular ultrasonogram (Figure) wasobtained owing to continued pain in the right scrotum and inability to evaluate the testicle. After viewingthe ultrasound pattern, the patient was promptly taken to the operating room 6 hours after onset ofsymptoms. [West J Emerg Med. 2012;13(1):131–132.]

Infectious Disease

Haemophilus influenzae Sepsis and Placental Abruption in an Unvaccinated Immigrant

Background: Haemophilus influenzae infections have declined dramatically in the United States sinceimplementation of the conjugate vaccine. However, in countries where widespread immunization is notroutine, H influenzae remains a significant cause of morbidity and mortality. We report a case of apreviously unvaccinated immigrant with confirmed H influenzae sepsis and placental abruption leadingto spontaneous abortion.

Objectives: To alert emergency medicine practitioners that H influenzae should be recognized as amaternal, fetal, and neonatal pathogen. Clinicians should consider this diagnosis in immigrants presentingwith uncertain vaccination history, as H influenzae can cause significant morbidity and mortality.

Case Presentation: A 36-year-old female was referred to our emergency department (ED) with lowerabdominal pain with some vaginal spotting. The patient had an initial visit with normal laboratoryinvestigations and normal imaging results, with complete resolution of symptoms. The patient returned tothe ED with sudden onset of vaginal bleeding and abdominal pain. She presented at this time with sepsis,which progressed to septic shock, causing placental abruption and ultimately, spontaneous abortion. Thepatient was treated with pressors and antibiotics and was admitted to the medical intensive care unitwhere she received ampicillin, gentamycin, and clindamycin for suspected chorioamnionitis. The patient’sblood cultures came back positive after 1 day for H influenzae. The patient did well and was dischargedfrom the hospital 4 days later.

Conclusion: Haemophilus influenzae should be recognized as a neonatal and maternal pathogen.Clinicians should consider this diagnosis in immigrants presenting with uncertain vaccination history,especially in pregnant females, as H influenzae can cause significant morbidity and mortality. [West JEmerg Med. 2012;13(1):133–135.]


Dermatomyositis with Extensive Calcification in an Adult

This report reviews a case of dermatomyositis presenting with weakness and extensive calcification inan adult. While dermatomyositis is not uncommon in adults, it is uncommon for calcifications to bepresent. Children develop calcifications more frequently than adults. When present in adults, smallcalcifications on areas of frequent trauma such as elbows and fingers are more common. However, thispatient presented with large calcified deposits in his abdomen and extremities. His treatment andcourse are described. [West J Emerg Med. 2012;13(1):136–138.]

Discourse on Integrating Emergency Care and Population Health

Reply to Gabaeff

The Western Journal of Emergency Medicine has received a detailed critique by Dr Christopher Greeley of the article, ‘‘Challenging the Pathophysiologic Connection between Subdural Hematoma, Retinal Hemorrhage, and Shaken Baby Syndrome’’ by Dr Steven Gabaeff, published in May 2011, Volume XII, Issue 2. The author’s response is even more detailed. The Journal recognizes that these 2 authorities are diametrically opposed in their opinions, and in the interest of fair academic discourse, we are publishing both the letter to the editor and response to the editor in electronic form for those interested in this highly contentious debate.We leave it to the reader to judge the original article, its critique, and rebuttal, on their own merits.The Editor