Psychosocial and Behavioral Emergencies
What to know
Behavioral emergencies require ruling out medical causes before assuming a psychiatric origin. Delirium is acute, fluctuating, and marked by inattention; new psychosis in an older adult is delirium until proven otherwise. Check vital signs, glucose, oxygenation, and medications. Suicide risk assessment covers ideation, intent, plan, means, previous attempts, and protective factors, and means restriction matters. De-escalation is first-line: calm environment, adequate space, and clear communication. Restraints are a last resort, require an order, must be the least restrictive option, and demand frequent monitoring of circulation, breathing, and behavior. Severe agitation and excited delirium are medical emergencies with risk of sudden death. Alcohol and sedative withdrawal can cause seizures and delirium tremens, treated with benzodiazepines and thiamine.
Traps
Never attribute agitation to a psychiatric cause without a medical workup. Do not leave a restrained patient unattended. Avoid arguing with or confronting a paranoid patient. Remember that patients with serious mental illness have higher rates of physical illness.
Worked example
A 78-year-old with no psychiatric history becomes acutely agitated and sees things that are not there. Check glucose and oxygenation, and look for infection, urinary retention, or medication effects before calling psychiatry. Rule of thumb: an acute change in mental status is delirium until proven otherwise.