Pediatric emergency medicine trisk 1040

children may also have concomitant medical problems and, in fact, are at
greater risk for presenting with emergent medical conditions such as injuries
and ingestions than are nonpsychiatrically ill children.
A thorough medical history, including current medication and possible
ingestions, followed by a complete physical examination, including a
complete neurologic examination is all that is required for the majority of
patients. There is no “standard” set of laboratory evaluations that must be
obtained to “clear” a psychiatric patient. Patients with new onset of or acute
change in psychiatric symptoms, especially psychosis or alterations in
mental status, must be carefully evaluated for possible underlying medical
conditions. These patients may require additional laboratory evaluation or
subspecialist consultation. In addition, some psychiatric facilities may
request or require baseline laboratory data before accepting a transfer.
Toxicologic screens and pregnancy tests in postpubertal teens are the most
frequently obtained laboratory tests. Table 126.2 lists laboratory evaluations
that may be considered for psychiatric patients.
TABLE 126.2
SCREENING TESTS FOR MEDICAL ILLNESS
1. Complete blood cell count with differential
2. Complete blood chemistries (including measurements of electrolytes,
glucose, calcium, and magnesium levels and tests of hepatic and renal
function)
3. Thyroid function tests
4. Pregnancy test
5. Urinalysis
6. Urine and serum toxicology screen
7. EKG
8. Plasma levels of any drugs being taken, if appropriate
9. Neuroimaging (if clinically indicated)
10. Lumbar puncture (if clinically indicated)
EKG, electrocardiogram; CT, computed tomography.

Adapted from Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Synopsis of Psychiatry . 9th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2003:24.


TABLE 126.3
CHILDHOOD/ADOLESCENT PSYCHIATRIC EMERGENCIES:
CHILD MENTAL STATUS EXAMINATION
Orientation
Appearance
Memory
Cognition
Behavior
Speech
Mood and affect
Thought process
Thought content (including suicidal ideation, homicidal ideation,
obsessions, delusions, hallucinations)
Insight and judgment

Mental Status of the Child
Evaluation of the child’s mental status takes place throughout the entire ED
visit. The mental status examination provides a psychological profile of the
child and contributes to the assessment of psychiatric diagnoses. Frequently
much of the relevant data often emerge during the history, physical
examination, and interactions with the child and family members. The
emergency physician should have a systematic and thorough understanding
of the mental status examination and should follow up any areas of concern
with more specific questions. Table 126.3 lists the major categories of the
mental status examination, with a focus on the aspects most relevant to
emergency psychiatric assessment.

Family Evaluation
The mental status of the family can be assessed while observing the
presentation of the history and the interactions of caregivers with the patient
during the ED visit. The presentation of caregivers should be coherent and
logical and should follow a temporal sequence. Family members under the
influence of drugs or alcohol may not be fully alert and oriented. Depressed
parents may appear withdrawn and downcast and may be so preoccupied


with their depression that they do not focus effectively on the child’s
problem or may blame the child for their own problems. Families that do not
present with organized mental and social functioning may have serious
difficulties resolving crises ( Table 126.4 ).
The goal of a family evaluation for childhood psychiatric emergencies is
to determine the methods they use to help the child when distressed, how
well these work, and gauge the willingness to try new strategies to help with
the current crisis. When the physician approaches parents as partners, the
likelihood of an effective collaboration between parents and medical staff is
maximized.

Using Social Support
Some families come to the ED feeling isolated, overwhelmed, and
exhausted. Often, such families have not used all the family and community
resources available to them. Effective crisis intervention for psychiatric
emergencies involves not only emergency treatment but also effective
disposition planning for the family. The ED staff should determine what
other family members and community resources are available to the family.

TABLE 126.4
CHILDHOOD/ADOLESCENT PSYCHIATRIC EMERGENCIES:
FAMILY ASSESSMENT
Signs of competence and strength
Level of concern
Verbal communication
Problem-solving ability
Relationships
Parents and child
Parents or caregivers
Parents and physician
Danger signs with parents/caregivers
Psychosis
Intoxication/drug abuse
Depression
Violence
History of abuse (physical, emotional, sexual) and/or neglect

Resources for ED Clinicians
The American College of Emergency Physicians (ACEP), the American
Academy of Child and Adolescent Psychiatry (AACAP), and the Substance
Abuse Mental Health Services Administration (SAMHSA) have a number of
online resources which may assist ED clinicians, including a National
Helpline ( ), Treatment
Locators ( , />),
and
substance
use
disorders
( />,

/>,
/>e_Use_Resource_Center/Home.aspx ).