Managing Acute Psychosis Emergencies
Whether it be at a college party or in the nursing home at 3 AM, managing an acute psychosis patient is something EMTs and Paramedics encounter with frequency during their tenure. A college student under the influence of mind-altering drugs and an elderly person suffering from sequelae of brain disease can be very similar sometimes… who knew!
Today I wanted to talk about acute psychosis, a term that describes a patient’s mental disconnection from reality due to a various array of conditions. Most, if not all, prehospital clinicians will experience encounters with patients who have acute psychosis. Often, we will be the first ones with this patient, giving us an ability to gather key clues to the trigger that caused the psychosis. Understanding the prevalence, assessment, and management is key to proper patient care.
Epidemiology
The general population has a lifetime prevalence of 3% for the development of acute psychosis, with acute psychosis due to a general medical condition accounting for 0.21%.1 One study conducted in an urban area showed the most common associated diseases with the presentation of acute psychosis were depression (42.4%), anxiety (38.6%), and panic disorders (24.8%). Acute psychosis associated with substance use disorders was at 13.8%.2
What does this mean for you as EMS personnel, and why should you care about disease epidemiology? While only 0.21% of acute psychosis patients were associated with a general medical condition, those general medical conditions can be associated with life-threatening vital sign abnormalities and organ dysfunctions that need to be recognized quickly. While true psychiatric emergencies are emergencies, it is important to understand that so-called organic dysfunctions (e.g., thyroid storm, sepsis) can cause acute psychosis as well, and often require prompt pharmacological and procedural interventions.
Assessment and Prehospital Diagnostic Work-up
Psychosis can present with symptoms of delusions, hallucinations, thought disorganization, and agitation/aggression, as detailed below 3. As a prehospital provider, your assessment and subsequent recording of the following events are extremely helpful in the future care and management of the patient (who may be in a very different state of mind upon arrival to the hospital).
Delusions: strongly held false beliefs that are not typical of a patient’s cultural or religious background, further categorized as bizarre or non-bizarre. For example, a belief that family members have been replaced by aliens in skin suits is bizarre, while a belief that a spouse is having an affair is non-bizarre. Delusions are also divided into types such as persecutory, grandiose, somatic, etc.
Hallucinations: the sensory experience of content that is not there (as opposed to illusions, which are distortions of real sensory stimuli). Hallucinations can occur in any of the 5 sensory stimuli, but auditory hallucinations are the most common. A “street” rule-of-thumb (not a strict rule by any means) is that auditory hallucinations are commonly associated with psychiatric disorders, and visual hallucinations are commonly associated with drug/infectious causes.
Thought Disorganization: alterations in the patient's pattern of speech. Disorganized speech is often present in acute psychosis but is nonspecific as it is seen in cases of delirium and other neurocognitive disorders. Common forms include:
Alogia/Poverty of Content: little information conveyed by speech
Thought Blocking: losing train of thought / abrupt interruption in speech
Tangentiality: inability to answer a question without giving excessive, unnecessary detail and derailment of the topic
This is where my favorite part of medicine becomes crucial - taking on the role of the medical detective. A thorough interview with the patient and any family/bystanders is crucial in helping to build a differential diagnosis and determining the underlying cause. Of note, the following are important to determine:
Timeline of symptoms (when did you notice something was different when was the last known well time)
Psychiatric history
Substance use history
Family history (including a family history of psychiatric illness)
Medical history (particularly an in-depth neurological exam)
In my opinion, this is the most important role for the EMT or Paramedic in the assessment and management of an acutely psychotic patient. Not only are you seeing the patient for the first time, but you are seeing them in their environment where their disease is manifesting outside of a hospital setting. You can note their appearance (grooming, hygiene, home status) and general behaviors in their environment!
Additional diagnostic workup that can be performed in the field is a fingerstick blood glucose to assess for blood sugar abnormalities, and a 12-lead ECG to assess for evidence of electrolyte abnormalities. If your shop draws blood, and the patient is amenable to it, draw it in the field to expedite the process in the hospital. Shown here is an excellent summary table from the American Academy of Family Physicians that delineates the many causes of acute psychosis.
Management
The primary point of management in the care of acutely psychotic patients is making sure you are safe, your team is safe, and the patient is safe from harming themselves or others. Although the data is inconclusive regarding the efficacy of verbal de-escalation in managing psychosis, it should be attempted first (but not at the risk of harm to anyone, including the patient) 4,5. In talking with these patients, it is important to speak to them honestly and straightforwardly; likewise, friendly gestures appear to go a long way in allowing mental decompression and opening up (e.g., offering a chair to sit, or food or drink) 6.
The second-line treatment is pharmacological intervention; and for most EMS systems that means a first-generation antipsychotic, benzodiazepines, or ketamine. Although the role of ketamine in acute psychiatric disorders is hotly debated, the literature is starting to show that it is safe for use in prehospital environments and emergency departments for the control of psychomotor agitation and violent behavior 7,8,9.
Physical restraints can include soft restraints and up to handcuffs via police in the prehospital environment. While the use of restraints is humane and effective in the treatment of the patient and injury prevention to both patient and staff 10,11, it is important for prehospital personnel not to place patients prone or in hobble positions as that has resulted in deaths due to asphyxia 12.
Summary
The causes of acute psychosis are broad and varied, but a solid history and physical examination are key in determining the underlying cause of the disease. While the prevalence of organically caused acute psychosis is low, it is important to remember that is a potential factor in your patient - thus, your threshold for medically managed intervention should be low (after stabilizing the patient and your scene). Assessment of patients suffering from acute psychosis can be extremely challenging but being nice and honest seems to go a long way. The management of these patients is straightforward: make sure everyone is safe, and don’t be afraid to escalate to pharmacological intervention. Be cautious with physical restraints! In the end, as most things do, it comes down to a solid history taking surrounding the patient’s events that led them to their acute psychosis.
Sources
Perälä J, Suvisaari J, Saarni SI, et al. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry. 2007;64(1):19–28.
2 Olfson M, Lewis-Fernández R, Weissman MM, et al. Psychotic symptoms in urban general medicine practice. Am J Psychiatry. 2002;159(8):1412–1419.
3 Sadock BJ, Sadock VA, Kaplan HI. Kaplan and Sadock's Comprehensive Textbook of Psychiatry, Lippincott Williams & Wilkins, 2009. Vol 1.
4 Du, M., Wang, X., Yin, S., Shu, W., Hao, R., Zhao, S., … Xia, J. (2017). De-escalation techniques for psychosis-induced aggression or agitation. Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.cd009922.pub2
5 Spencer, S., Johnson, P., & Smith, I. C. (2018). De-escalation techniques for managing non-psychosis-induced aggression in adults. Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.cd012034.pub2
6 Hill, S, and J Petit. “The Violent Patient.” Emerg Med Clin North Am, vol. 18, no. 2, May 2000, pp. 301–315.
7 Barbic, D., Andolfatto, G., Grunau, B., Scheuermeyer, F., MacEwan, W., & Honer, W. et al. (2018). Rapid agitation control with ketamine in the emergency department (RACKED): a randomized controlled trial protocol. Trials, 19(1). doi: 10.1186/s13063-018-2992-x
8 Scheppke, K., Braghiroli, J., Shalaby, M., & Chait, R. (2014). Prehospital Use of IM Ketamine for Sedation of Violent and Agitated Patients. Western Journal Of Emergency Medicine, 15(7), 736-741. doi: 10.5811/westjem.2014.9.23229
9 Swaminathan, A. (2018). Is Ketamine Contraindicated in Patients with Psychiatric Disorders? - REBEL EM - Emergency Medicine Blog. From https://rebelem.com/is-ketamine-contraindicated-in-patients-with-psychiatric-disorders/
10 Tardiff K. Adult antisocial behavior and criminality. In: Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 7th, Sadock BJ, Sadock VA (Eds), Lippincott Willaims & Wilkins, Philadelphia 2000. Vol 2, p.1908.
11 Allen MH. Managing the agitated psychotic patient: a reappraisal of the evidence. J Clin Psychiatry 2000; 61 Suppl 14:11.
12 Reay DT, Fligner CL, Stilwell AD, Arnold J. Positional asphyxia during law enforcement transport. Am J Forensic Med Pathol 1992; 13:90.
This article was reviewed and edited by the Overrun Productions team before submission and publication.
