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Serum iron and mental status changes: when people are anemic they can feel kind of low, sluggish. That’s one of the symptoms of iron-deficiency anemia. The whole gestalt of this is a person comes in with psychiatric symptoms. “I feel confused, I feel anxious. My husband is confused.” The first thing we want to do is rule out a general medical condition that we can reverse. Like, “Oh, your magnesium is low” or “Oh, you are not getting enough iron because you’ve got this bad GI bleed going on” or “Oh, your thyroid is off.” Once we’ve done all of that we say, “Okay, you’re not going to die. Go to the psychiatrist and he’ll give you some psychiatric medication.” Now even though the psychiatric condition, the schizophrenia, the depression, is very biological, it’s very medical. Here we are at the end of the 20th century and we don’t have a neat little test that we can say, “Okay, you have schizophrenia because it showed up on our PET scan”. We are there experimentally but we are not there clinically. In 100 years you’ll probably be able to send most psychiatric patients, I’m thinking, to the lab or the radiologist and he will say, “Yes, here’s your psychiatric diagnosis. This is schizophrenia, this is manic depression.” But basically those are all still clinical diagnoses.

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Hypokalemia: one of those is because of poor nutrition and another is eating disorders. These bulimic women - and believe me, it tends to be a disease of women - will vomit, will make themselves vomit and then they will get hypokalemic. Also, here’s a trivia question. There’s also a certain type of food that, if you eat a lot of, will cause hypokalemia. Does anyone know what that is? Licorice. Yeah, certain types of black licorice will cause hypokalemia. Every once in awhile you will see this case report and you’ve got this poor, young bulimic who loves to binge on licorice. She is just eating strands and strands of black licorice and then throwing it up, and her potassium is in the basement as a result of that.
EKG abnormalities: thioridazine can cause quinidine-like effects, such as prolonged TP and CR intervals. That’s important to know. Mellaril, or thioridazine, that is the least heart-healthy of your antipsychotics probably. Lithium can cause T-wave flattening or inversion. Looks like hypokalemia. TCA overdose, classically QRS widening and anorexia can result in bradycardia or other arrhythmias. Kind of another neat point is sometimes what you will see on psychiatric units, a common cause of bradycardia - mild bradycardia - is nicotine withdrawal. Now hospitals are all non-smoking, including psychiatric units and you’ll see these people - they’ll have a slow heart rate sometimes. Most substances, when you withdraw, you get tachycardic, as you know. Nicotine is the reverse of this. It’s kind of paradoxical. The heart rate can slow down.
There is one where you’ve got to get an EKG. Lithium, no question. You want an EKG. There were a few tragic deaths with one of the TCAs, desipramine I believe. There were a few kids who died unfortunately, in a relatively short period of time, because they were put on desipramine. There were like six kids cialis professional and in a short period of time three of them died and three of them, I guess, lived. But they had fatal arrhythmias from desipramine. So in pediatric populations we like to get EKG’s. But in your young, healthy adult - let’s say somebody comes in for pain - “Hey doc, I’ve got headache.” You are going to put them on Elavil, amitriptyline - which I’m assuming is still used by neurologists for pain. Probably not. It’s always nice to get an EKG but I don’t think most people would say this is mandatory to get an EKG. Anybody with heart block is at risk for having a TCA, so it’s nice to have an EKG but I don’t think it’s standard of care like it is with lithium.

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Tips for dealing with aggression. Avoid any verbal confrontation if possible. Offer food and cold liquids. I once saw a psychiatric outline in a course like this where they said, offer the patient coffee. Agitated patients, coffee, no. Not unless you want to be wearing it. So offer food and cold liquids. I mean, you know how it is. You come home from work and you are kind of cranky. You have something. Somebody says, here’s a sandwich and a nice glass of Pepsi. You feel better. It’s like, “Okay, I was kind of irritable but now I feel better.” Works the same way with confused patients in an ER. You give them a cold sandwich and a glass of pop and a lot of times they will calm down. Avoid eye contact with intensely paranoid patients. Some cultures are different. As you know, in the American culture we like to make eye contact and that’s seen as a sign of honesty. There are some cultures where it is thought to be rude if you look people directly in the eye. For paranoid patients, don’t look at them in the eye. Look away or look down because a lot of people find that very intimidating and confrontational.
Let the patient vent. Cialis professional pharmacy. This is so important. Chlorpromazine or Thorazine can cause hypotension. Get these elderly people, or even young people, and they suddenly go from agitated to on the floor, clunk. Then you have to call the radiologist because you’ve got to get a CT scan. Haloperidol or Haldol is very nice because it causes essentially no hypotension.
Apart from drugs, non-pharmacological options is letting the patient vent.
Supportive therapy, including cooling blankets, ice baths, hydration, maybe Tylenol. How about dantrolene and bromocriptine? In real life, probably not. For the Board, probably so. I don’t think in looking at the literature, and I’m not the internationally recognized authority on NMS, but looking at the literature I don’t think that bromocriptine or dantrolene really help. I don’t think they are any better than just supportive therapy. But if I were answering the question on the Board, I would pick one of those two. How about Sinemet? Have people ever heard of that or used that? I have read that, that Sinemet causes NMS. It’s not something I classically associated with NMS. How many people have ever heard that? Using Sinemet? What’s that? Can cause NMS? Okay, have you ever heard about it for just people who get it from Haldol, where it is not Sinemet caused?
Laboratory abnormalities. The most common laboratory abnormality in a psychiatric patient is hyponatremia. Why is that? There is a classic med that you use and that I use, Tegretol, carbamazepine can cause hyponatremia. One that I use a lot that you probably don’t prescribe, clozapine. Clozaril, which we’ll talk about at length. That was the first traditional antipsychotic, that’s the agranulocytosis one and we’ll talk about that, that can cause hyponatremia. Also lithium possibly. People on lithium like to drink a lot of water. And then, Depakote. How many of you have seen Depakote hyponatremia? I don’t think of that as classically but I’m sure you’re right. Then finally, psychogenic polydipsia. What’s psychogenic polydipsia? Psychiatric patients sometimes, like in state hospitals - and now sometimes in the community because nobody is in state hospitals anymore - will just drink and drink and drink. They will just drink until they dilute all their sodium. Their sodium will go down to like 108 and then they’ll have seizures.

Treatment of severe anxiety. In the emergency department, 1-2 mg of Ativan is a very good standard. Some people like to use Herbal Xanax. But I think Ativan is a really good standard. When you are choosing a benzodiazepine I like … another reason Ativan is a good choice as a sort of standard benzodiazepine to use is, one, it’s clean so it has no active metabolites. You can use it in all three forms, IM, PO or IV. You can use it in the elderly.
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The suicidal patient. About 30,000 suicides annually in the U.S. Suicide is very impulsive. That’s why people with substance abuse are at particular risk for suicide because they get drunk - I’ve seen it over and over. You work in an ER or you do consulting as a psychiatrist in an ER, over and over. The person comes in, the police are called. They take the gun away from them because the wife called the police. They had the gun to their head. You see them at 9 o’clock in the morning back. “I’m fine, I’m fine. There’s no problem. I’m not suicidal. I don’t’ know what the hell I was doing, I don’t even remember it. I just want to go home. And no, I’m not depressed.” You see this over and over. For some people, alcohol is like a suicide potion. So what happens is, if the people are around other people or someone can get the gun away from them, they are fine. But if they are alone in the middle of the night and all they have is that six-pack of beer and that shotgun, then it’s a very lethal combination. And, guys like guns. Men use more lethal attempts. Women, you’ll see a lot more of these subacute attempts.
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Risk factors for suicide: the older you get, the more you are at risk for suicide. Elderly males have the highest rate of suicide.
Management of the suicidal patient: somebody comes into the ER or your office and they are talking about suicide, what do you do? Number one, try to assess the seriousness of the risk. Does it seem real? And there’s no science to this. The more you do it, obviously if you are a mental health crisis worker, every night you are on call you see two of these people and you get better at assessing the risk. Nobody can predict who is going to kill themselves in the near future.
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A lot of people who kill themselves really are a mystery. They will have a freezer and a refrigerator full of food, they will have recently renewed all their magazine subscriptions. It’s really a mystery and I think one of the answers to that mystery is what I said before; suicide is very very impulsive. A lot of times people will have the idea in their head, and there are people who think about it every day or every other day of their lives, but sometimes it’s the right hour, they have the right means, they have the gun, it’s the middle of the night - and if it were the middle of the day and they were at the mall there would be no problem - but they are alone in the middle of the night and suddenly they get that, “I know what I have to do.” It’s kind of like that phone call that you know you have to make but you dread making it and then suddenly it’s like, “Okay, fine. I’ve got to get this out of the way. I’ve got to make this phone call.”
Violent patients. There’s two kinds of really violent patients. There’s one where they are agitated secondary to confusion, and the other where they are just kind of sociopathic and criminal. Number one: assess and treat the medical issues above. Use Haldol and lorazepam like we talked about. Antipsychotics like Haldol can cause dystonia. What’s dystonia? It’s that twisting of the neck, rolling of the eyes, sticking out of the tongue.

Now advantages of Librium. First of all, which has the longer half life? Ativan or Librium? Which lasts longer? Librium does. Why is that an advantage? Well, let’s say you are at some small hospital, small rural hospital, where the nursing staff is not really what it should be and somebody misses a dose of the medication. You are covered if you’ve got Librium and you are not covered if you have Ativan. Let’s talk about the more likely, patient signing out AMA. Do alcoholics like to sign out of the hospital AMA? Yes they do. Why do they do that? So they can go and drink. So it’s not uncommon for them to say, heck with this doc. I’m out of here. Give me the AMA forms. You start talking to them and they are just, “Gimme the forms, gimme the forms.” And where’s the first place they go? The bar or the liquor store to appropriate some medication for their withdrawal feelings. By the time they get from the hospital door to the bar they are covered if they are on Librium. They are not going to start to show withdrawal, which they may show if they are on a shorter acting benzodiazepine like lorazepam. So that’s an advantage of chlordiazepoxide or Librium. Generic medications online at Licensed Generic pharmacy.
Librium is more accepted. Also Tegretol. You can load somebody with Tegretol, give them like 400 bid. Tegretol is carbamazepine, not really a GABA receptor thing. Of course, we know why the benzodiazepines are thought to work for alcohol. There’s cross-tolerance with GABA. You know, Tegretol really doesn’t have that but for some reason it seems to help prevent even alcohol withdrawal seizures and symptoms in addition to just the seizures. Common dose: Librium 50 mg qid. then taper after 48 hours.
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Severe anxiety. Because we want to distinguish between panic attacks and generalized anxiety disorder, which we will talk about later in the day. Is it new? Again, it kind of goes along with the confusion. If this is new then it’s more of an emergency type of thing. If it’s not new, then we are not as worried about it from an emergency perspective. Although you still may have to deal with it as a physician. Has it been worked up and/or treated? What’s your medical history? Any psychiatric or substance abuse? Important question: how much caffeine do you use? There are people out there who will have panic attacks if they have three cups of coffee per day. But ask about caffeine. Any over-the-counter drugs? Things like Mini-Thins, that’s like pseudoephedrine and those kinds of things they have back in Michigan. Sometimes kids and people older than kids - young adults and middle-aged people - will abuse these over-the-counter ephedrine type things or over-the-counter caffeine pills. When was the last time you ate? There’s two reasons to ask that. One is, what are we thinking about if they haven’t eaten all day and now they are anxious and dizzy? Hypoglycemia. Another important reason we ask that is, it could impair the absorption of the benzodiazepine. If they’ve got a full stomach and we give them two Xanax in the ER it might take a little while longer for their anxiety to calm down. So that’s two key questions. It’s not that they need Xanax. What they need is a peanut butter sandwich.

If the studies are within normal limits, much has been done to rule out an acute medical condition. But let’s say you have all the time and all the money in the world. You say, “Look, we’ve done all this acute stuff, we said they are not going to die in the next hour, what do we do now?” I’m the only neurologist in town, there is no psychiatrist, I’ve got to pretty much do everything myself, what do I do? Consider an MRI to detect a CNS lesion. Consider a EEG. Sometimes subtle forms of seizures, as you know, can present with confusion. These second tier of laboratory studies, things they probably wouldn’t do in an ER but might do on a psychiatric unit; iron, magnesium, B12, folate, thyroid panel and VDRL. Then if you want to rule out everything in the world - say you’ve got a 20-year-old. He comes in, he’s confused. You’ve done all this stuff and you are probably thinking at this point, what? You’ve done all these studies and everything is negative and this kid is still confused, what do you think it probably is? Probably schizophrenia. You’ve probably got a kid who has got an underlying psychiatric condition. But what you want to do in a 20-year-old is you want to spend every last dollar before you say, oh this is schizophrenia and let’s treat it like schizophrenia. Because every psychiatrist’s worst nightmare is treating some kid for schizophrenia for five years and then seeing one day a Kayser-Fleischer ring. Oops. The kid had Wilson’s disease all along. So the “every-last-dollar-workup” is you want to get a serum ceruloplasmin and there are some other things with the Wilson’s workup. ESR, ANA and heavy metal screening.
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Treatment of confusion. Number one treat the underlying cause, then treat agitation if present.

The confused alcoholic. Keep the patient in the hospital if withdrawal is suspected. If there is a question of what to do with this alcoholic and he seems confused, his blood alcohol level has returned to normal, so it’s not just drunkenness and he doesn’t seem drunk. Confusion isn’t the same as drunkenness. They don’t know where they are, they don’t know what year it is, they are confused. Don’t send that alcoholic home because you are risking DTs, seizures and DTs. Once you see confusion, unfortunately, you may be heading into the DTs and once you head into the DTs there’s no going back. So if you keep them in the hospital, even if they are just drunk and not confused, you’ve got to prophylax for the DTs. So let’s say you keep the person in the hospital because you think they are confused, you think they might be a DT risk, put them on seizure precaution. Because they might seize, of course. Give them thiamin. A reasonable order is 100 mg IM times three, then 100 mg PO per day for the rest of the hospitalization. Give one multivitamin per day and PO folic acid. That’s a common order. Give benzodiazepine, typically chlordiazepoxide or lorazepam.
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When the psychiatrist is called to the emergency room because the patient is confused; somebody who is not acting their normal self the treatment should quickly rule out the potentially lethal and continue or refer their workup as appropriate for their subacute or sublethal condition. The patient can’t tell you what’s going on. They are having confusion, so you need somebody else to tell you, to give you part of the history. Elderly people are more apt to become confused with less of a medical insult. People, when they get older, don’t have the reserve that young people do and as a result a small medical insult will cause major mental status changes. What if you or I have a urinary tract infection? An elderly person with a urinary tract infection, their presenting complaint might be hiding themselves in their bedroom and closing the shades because they think the police are going to come and get them. So they can have mental status changes as the chief complaint in a mild pneumonia or a mild urinary tract infection.
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Another question: any psychiatric or substance abuse history? I think that’s pretty much self-explanatory. Quick review of systems. Any problem with head trauma, seizures or HIV risk? Then this is important; has there been a loss of alertness recently? Is this a new delirium or a chronic dementia? And we’ll talk about delirium versus dementia later in the day. Emergency rule-outs, kind of the quick things you want to go through. Wernicke’s encephalopathy. What do we see with Wernicke’s? Ataxia, sixth nerve palsy and confusion. That’s kind of the classic triad. Alcohol/sedative withdrawal. Hypertensive encephalopathy. What do we see with that? Papilledema, increased CSF pressure. But remember, hypertensive encephalopathy sometimes can be kind of chronic and you see this sort of mild personality stuff develop over time. Hypoglycemia. Is their blood sugar real low? Do they have a tremor? Are they dizzy? Hypoperfusion kind of goes along with hypoxemia. They are not perfusing well enough and that’s why they are confused. CNS bleed, meningitis or encephalitis. What do we see with meningitis? Stiff neck, photophobia, headache. And then acute and toxic metabolic causes and that list can be endless in and of itself.
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Initial workup of the confused patient: first, you assume there is a serious medical condition. You say, okay, there is something medically wrong with this person that needs to be reversed. Then when you have done that, you say, okay, it’s a functional problem. Call the psychiatrist. Functional is the word we use to describe not due to a medical condition. Although you may not find the cause of the confusion, and often you don’t, you want to at least rule out the potentially lethal conditions listed above. The physical exam is going to have a neurological focus, which is good because you are all neurologists. Initial diagnostic studies: chemistry profile, including electrolyte, CBC, U/A, EKG, also consider blood gas and pulse oximetry. Sometimes you want drug screening, depending on the circumstances. Obviously if they are older and in a nursing home you are probably not going to need that, but if they are a young person coming into the ER you definitely are going to need it. You want levels of commonly toxic medications like digoxin, anticonvulsants, such as Dilantin, lithium. Depending on the circumstances, you are going to want a CT scan. Sometimes a spinal tap, depending. Particularly if you are thinking something like meningitis.
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