Acute psychosis
(Redirected from Psychosis)
Background
- Loss of contact with reality characterized by hallucinations, delusions, and/or disordered thinking
- EM priority: Rule out medical (organic) causes before attributing to primary psychiatric illness
- First-episode psychosis, age >40 onset, or atypical features should always prompt thorough medical workup
- Causes: schizophrenia, bipolar disorder, substance intoxication/withdrawal, medical illness (infection, metabolic, neurologic, endocrine)
Clinical Features
- Hallucinations (auditory most common in psychiatric; visual more suggestive of organic cause)
- Delusions (paranoid, persecutory, grandiose)
- Disorganized speech or behavior
- Agitation, restlessness, irritability
- Decreased attention
- Inappropriate or hostile behaviors
- +/- additional features of underlying pathology (signs of intoxication/withdrawal, trauma, focal neurologic deficits)
Red Flags Suggesting Medical Cause
- Age >40 with no psychiatric history
- Acute onset (hours to days)
- Visual hallucinations predominant
- Altered mental status, clouding of consciousness (suggests delirium)
- Vital sign abnormalities (fever, tachycardia, hypertension)
- Focal neurologic findings
- Recent medication changes or new substances
Differential Diagnosis
Altered mental status
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
- Hypertensive Encephalopathy
- Toxins
- TTP / Thrombotic thrombocytopenic purpura
- Alcohol withdrawal
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Wernicke encephalopathy
- Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
- Sepsis
- Osmotic demyelination syndrome (central pontine myelinolysis)
- Limbic encephalitis
Primary CNS disease or trauma
- Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
- Vascular disease
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic encephalitis
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
Psychiatric Disorders with Psychotic Symptoms
- Acute psychosis
- Schizophrenia
- Schizoaffective disorder
- Delusional disorder
- Schizotypal personality disorder
- Schizoid personality disorder
- Bipolar disorder with psychotic features
Evaluation
- Rule out organic causes before attributing to primary psychiatric illness
General ED Psychiatric Workup
- Point-of-care glucose
- CBC
- Chem 7
- LFTs
- ECG (for toxicology evaluation)
- ASA level
- Tylenol level
- Urine toxicology screen/Blood toxicology screen
- EtOH
- Urine pregnancy/beta-hCG (if female of childbearing age)
- Consider:
- Ammonia (see Hepatic encephalopathy)
- TSH (hypo or hyperthyroidism may mimic mental illness)
- CXR (for Tb screen or rule-out delirium in older patient)
- UA (for rule-out delirium in older patients)
- Head CT (to rule-out ICH in patients with AMS)
- Lumbar puncture (to rule-out meningitis or encephalitis)
- Consider: glucose, BMP, CBC, urine toxicology screen, TSH, urinalysis, ECG
- CT head if: first episode, focal neuro findings, altered consciousness, age >40, head trauma
- LP if meningitis/encephalitis suspected (fever + AMS)
Management
- Treat underlying condition first
- Ensure scene safety — de-escalation techniques before pharmacologic intervention
General ED Psychiatric Management
- Non-pharmacologic
- Verbal de-escalation
- Offer comforting items: blanket, meal, pillow, etc
- Quiet room
- Physical restraints (should administer medications if restraints used, as decreases restraint time)
- Pharmacologic: Goal is to calm patient without oversedation
- No history of psychosis
- Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
- Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
- Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg (PO/IM/SL) or ziprasidone 10-20mg IM
- Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
- Known or suspected underlying psychotic illness
- Continue treatment with previous antipsychotic or
- PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
- IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
- (PO/IM/IV) Haloperidol 0.5-5mg +/- lorazepam 0.5-2mg
- Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
- No history of psychosis
- Pharmacologic management of acute agitation:
- Haloperidol 5-10 mg IM + lorazepam 2 mg IM + diphenhydramine 50 mg IM (classic B52 cocktail)
- Olanzapine 10 mg IM (avoid with benzodiazepines — risk of respiratory depression)
- Midazolam 5 mg IM (fastest onset for severe agitation)
- Ketamine 4-5 mg/kg IM for severe undifferentiated agitation
- Avoid restraints when possible; use least restrictive measures
Disposition
- Depends on underlying cause
- Admit/psychiatric hold: first psychotic episode, suicidal/homicidal ideation, unable to care for self, poor support system
- Discharge: known psychiatric disorder with exacerbation, medically cleared, safe disposition plan, psychiatry follow-up