Basic Psychiatric Assessment

Every psychiatric call is different. There are many psychological, emotional, and chemical processes in the brain that we don't understand completely and can be hard to diagnose and manage.

Assessing psychiatric issues in patients starts with looking at basic characteristics like their speech, skin color or turgor, general appearance and coordination, and mental status. Psychiatric patients may have altered moods, perceptions, memories and attention.

There are many things that may alter a personal behavior and which may include physiologic and/or psychologic illness, or the patient may be under the influence of mind-altering substances.

Common Causes of Behavioral Alteration

1. Low blood sugar: a blood glucose determination is indicated in any behavioral alteration.
2. Lack of oxygen: pneumonia, COPD.
3. Shock.
4. Head trauma.
5. Mind-altering substances.
6. Psychiatric.
7. Excessive cold.
8. Excessive heat.
9. Brain infection: encephalitis is a complication of infection in the CNS that involves mental changes.
10. Brain cancer/CNS mass lesions.
11. Hypertensive encephalopathy.
12. Intracranial hemorrhage/stroke.
13. Dementia.
14. Seizure disorders.
15. Poisoning or overdose.
16. Withdrawal from drugs or alcohol.
17. Hyperthyroidism: "Thyroid storm" is a life-threatening emergency.
18. Panic attack: panic attacks often occur at times of significant life stress. Panic attacks usually are triggered by fear and are self-limited; attempting to "talk someone down" may be difficult since the patient, by the very nature of the panic attack, is in a trance of sorts.
19. Electrolyte disturbances: all conditions associated with or causing electrolyte disturbances can present with confusion.

Danger to Others or to Themselves

SAFETY FIRST: Psychiatric patients, or any patient, can become a legitimate physical threat to the emergency provider at any time. Special attention and backup resources are required in patients who are complaining of agitation, hallucinations or paranoia, or who become a danger to themselves or others. Protect yourself and your crew first and make sure your scene remains safe.

Patients with psychiatric complaints should be assessed for suicide risk. Current or prolonged depression can lead to feelings of hopelessness and a desire to end one's life. In order to gain an overall view of the patient's well-being and/or predict whether the patient may become a danger to himself or others, there are several questions to consider:

1. Is the patient thinking about hurting or killing himself or anyone else?
2. Is the patient a threat to himself or others?
3. Is there an underlying medical problem causing the disturbance?
4. Could the psychiatric complaint be caused by head trauma?
5. Does the patient have access to any weapons?

Assessment

If a patient with altered behavior is awake and alert (does not have diminished level of consciousness or neurologic deficit from a stroke), evaluating his or her attention span and cognitive ability may help to distinguish confusion or delirium from primary psychiatric complaints.

Mental Status: Four core questions:

1.) Is there a diminished level of consciousness? (Rule out stupor/coma.)

2.) Is there an acute neurologic deficit? (Rule out stroke/mass lesion.) Neurologic deficits will manifest physically, such as with hemiparesis, facial asymmetry, visual field loss.

3.) Is there an acute attention deficit or short-term memory problem (Rule out confusion/delirium vs thought disorder.) 

• Attention deficit and short-term memory problems are typical of confusional states. The ability to shift attention and incorporate new information is necessary for daily functioning, and any inability with this is a symptom of confusion. Many psychiatric patients with depression or bipolar disorder have no trouble maintaining attention and performing cognitive functions, but those with medical or neurologic disorders cannot.
• Auditory hallucinations are more likely psychiatric.
• Visual suggest neurologic or medical disorders.

4.) Is there evidence of infection or other acute medical illness?

• Dehydration, fever, hypoperfusion, hypoxia. Drug toxicity can sometimes be identified by the pupillary response (myosis vs. mydriasis).

Management

The role of the EMR and EMT in the setting of a behavioral emergency is to attempt to calm the patient by offering transport to the nearest medical facility where shelter, food, water, and medical care can be provided. If the patient cannot be calmed or you feel that they continue to be a danger to themselves or others, contact another unit, supervisor, fire, or law enforcement for backup.