Beyond the Basics: Behavioral Emergencies

EMS providers should consider all behavioral emergencies altered mental status until proven otherwise.


CEU Review Form Behavioral Emergencies (PDF)Valid until December 6, 2006

A "psych emergency" call comes in for a patient who is talking to himself on a main street in town. You respond cautiously, and, although the police are on the scene, you scan it carefully for hazards. The patient is sitting on the steps of a family grocery talking with the police. The police officer sees you coming and smiles. "Ladies and gentlemen," he says, "I'd like you to meet the Lord."

     Before you can even formulate a response, the patient tells you, "It's OK. He doesn't believe me. But quite frankly, I have been taking persecution for years, and it continues to this very day."

     Anyone who has been in EMS for any amount of time has seen patients with delusional thoughts. Psychiatric emergencies are common calls for EMS providers. Some estimate that more than 20 million people in the United States are being treated for depression. To put this in perspective, a similar number of people experience asthma. Zoloft and Lexapro (antidepressants) and alprazolam (Xanax, for anxiety) were included in the top 20 most prescribed medications in 2005.

Altered Mental Status
     EMS providers should consider all behavioral emergencies altered mental status until proven otherwise. The stories of diabetic patients acting like they're drunk or experiencing behavioral emergencies are many-and costly, if this basic concept is overlooked.

     Even patients who have a history of psychiatric conditions can experience medical problems like diabetes. Medications taken for psychiatric conditions are powerful. Misuse-either intentional or accidental-can cause alterations in the patient's mental status and serious acute medical conditions.

     The mnemonic AEIOU-TIPS is commonly used to identify conditions in the differential diagnosis for altered mental status (Table I). Note that there are many versions of this mnemonic.

Pathophysiology of Psychiatric Disorders
     Articles much more extensive than this have been written about the causes of psychiatric conditions. While brain chemistry is the focus of pharmacologic treatment, some of the causes of psychiatric conditions remain less than clear.

     It is widely held that changes in levels of neurotransmitters in the central nervous system are responsible for conditions like depression. What makes listing an exact pathophysiology challenging is the fact that many people are not clinically depressed until a particular event or series of events occur in their life. This means that their neurotransmitters were either in a normal or subclinical range until some sort of emotional trauma caused changes in these important substances. Furthermore, in some cases, patients may be successfully treated without medications (behavioral and cognitive therapies) to improve conditions such as depression, anxiety and obsessive-compulsive disorders without altering neurotransmitter levels pharmacologically.

     Neurotransmitters send impulses through the synaptic cleft, commonly called synapse, or space, between two nerve cells. The neurotransmitter is released from the presynaptic neuron and crosses the synaptic cleft to the postsynaptic neuron. When the neurotransmitter binds to the receptor on the postsynaptic neuron, the cell depolarizes and propagates the impulse through the nervous system.

     The neurotransmitter is then broken down by an enzyme and undergoes a process of reabsorption or reuptake. This process occurs in milliseconds and is repeated continuously in the central nervous system. As mentioned previously, it is believed that a reduced level of neurotransmitters is responsible for conditions like depression.

Medications
     While medications are commonly discussed in the treatment category, in fact, there are few field medications for the patient with a behavioral emergency. Since many medications are designed to alter the level of neurotransmitters in the brain, this section logically follows here. Antidepressants will be used as an example, due to their prevalence in relation to other medications.

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