If you are following along in the curriculum I want to congratulate you on getting to this point. At this juncture we have completed the themes related to psychotic, depressive, bipolar, and anxiety disorders. During these themes we have also covered most of the medication classes which include antipsychotics, antidepressants, mood stabilizers, and anxiolytics.
Now that we have covered some of the fundamental disorders and medications within psychiatry I think it is an appropriate time to insert a theme related to important topics within emergency psychiatry. This will be a very practical theme and we will cover topics which will include medical clearance from the emergency department, suicide and violence risk assessment, management of agitation, and toxidromes.
We will start off this theme with today's topic of medical clearance.
Today's Content Level: Intermediate
INTRODUCTION
•“Medical clearance” is a term commonly used within psychiatry that refers to the process by which patients are medically evaluated in the emergency department (ED) prior to an admission/transfer to a psychiatric facility.
•In general, psychiatric units (with the exception of med-psych facilities) have a lesser capacity for the care of patients with active medical problems.
•The purpose of this evaluation is to identify, rule out, and/or stabilize medical conditions that would otherwise preclude a safe admission to a psych unit.
•Medical clearance does not mean that patients cannot have any medical issues at all, rather, the purpose is to determine medical instability or rule out conditions that are causative of the psychiatric presentation. 1
•Common examples that can cause/contribute to psychiatric symptoms that should be assessed in this evaluation include neurologic conditions, metabolic/endocrine disease, cardiopulmonary disease, infection, substance intoxication or withdrawal, medication side effects, and other general medical conditions.
STANDARD PRACTICES
•Unfortunately the process of “medical clearance” is varied and controversial and there is no evidence-based standard definition or process shared among psychiatrists or emergency physicians. 2
•There is also no agreed-upon panel of laboratory tests and/or imaging that is required. In my experience I have found this to vary significantly and it is often dependent on the institution. Always check your institutional requirements and follow those protocols but keep in mind that they are not always evidence based.
•Many studies have found that routine laboratory screening of all patients that present to an emergency department for primary psychiatric complaints is unnecessary and costly. A 2012 study found that only one of 502 patients who received routine labs on admission to a psychiatric hospital would have had their disposition changed, had these labs been drawn in the ED setting. 3
The authors of Pocket Psychiatry summarized the available research on this topic nicely and utilized recommendations compiled by the two main organizations that issue these guidelines -> The American Association for Emergency Psychiatry (AAEP) Task Force on Medical Clearance of Adult Psychiatric Patients and the Clinical Policy Committee of the American College of Emergency Physicians.
An appropriate history including a thorough review of systems by ED staff.
An appropriate physical exam, including vital signs and a robust neurological exam (paying special attention to cognitive functioning) by ED staff.
Laboratory tests and imaging as indicated by the findings of the above.
Special attention given to the following groups:
The elderly
Those with known prior medical conditions
Those with medical complaints or abnormal vital signs
Substance users
First psychiatric presentation, especially if outside the usual age range or with atypical or rapid onset of symptoms
Confused or cognitively impaired patients
•Ideally, medical clearance also includes recommendations regarding foreseeable medical needs after discharge or transfer. 4
POSSIBLE WORK-UP
•As mentioned previously, despite the lack of evidence for routine diagnostic testing, many psychiatric facilities will require lab workup prior to admission or transfer. Read below for a list of commonly and not so commonly ordered studies during the medical clearance exam.
Commonly ordered studies in the ED include:
CBC (complete blood count): helpful in ruling out infectious causes of altered mental status (WBC count). May also see changes in substance use disorders and patients taking certain psychiatric medications. Certain mood stabilizers, anticonvulsants, and clozapine suppresses bone marrow, so monitor RBC and WBC counts. Lithium may increase WBC count.
CMP (complete metabolic): used in altered mental status to rule out electrolyte disturbances (pay attention to sodium and calcium specifically), glucose (hypoglycemia or diabetic ketoacidosis), renal failure (creatinine and BUN). Also order in patients taking anticonvulsants or lithium.
LFTs (liver function test): this is commonly included in the CMP. Liver failure from alcohol, acute ingestions (ex: acetaminophen), fatty liver, or viral hepatitis can cause altered mental status and psychosis at its' extreme.
PT/INR: Useful in those with chronic liver disease, in patients on anticoagulation, and in those with concerns for acute hepatitis.
TSH (Thyroid Function): typically in the standard workup for most initial psychiatric presentations as both hypothyroidism and hyperthyroidism can mimic or complicate psychiatric disease such as depression and mania.
BAL (Blood Alcohol Level): useful in suspected intoxication. In general, psychiatric facilities will not accept acutely intoxicated patients. Some organizations recommend against the use of routine screening in patients without obvious signs of intoxication and normal cognition. Also keep in mind that the diagnosis of withdrawal (from alcohol or benzodiazepines) is more important in the ED than making a diagnosis of intoxication.
Drug Levels: obtain in patients taking medications for which there are clinically relevant drug levels. This can help rule out toxicity as well as help determine adherence. Examples include certain anti-epileptics, lithium, and clozapine. Drug levels should also be obtained in patients presenting for intentional or accidental overdose (commonly acetaminophen, salicylates, TCAs, etc…).
UDS (Urine Drug Screen): useful for most patients with psychiatric presentation and informs diagnosis, disposition, and treatment. It is rarely helpful, however, in the acute management of alert patients in the ED with noncontributory history, physical, and normal vital signs.
Urine Pregnancy Test: always indicated for psychiatric presentations of women of child bearing age.
UA +/- culture (Urinanalysis and culture): useful in symptomatic patients (such as dysuria) and in elderly patients with altered mental status.
EKG (electrocardiogram): obtain in patients with overdose, chest pain, known cardiac disease, elderly, abnormal vital signs, and prior to starting antipsychotic or other QTc prolonging agents.
Less commonly ordered studies in the ED include:
Other electrolytes (Ca, Mg, Phos): can be useful in patients with altered mental status, anorexia, and those with known arrhythmias or prolonged QTc.
Vitamin B1 (thiamine): thiamine deficiency over time can lead to something called Wernicke–Korsakoff syndrome. This is commonly from alcoholism or malabsorption. You WILL see someone with this condition at some point in your career. This is commonly missed. It is generally agreed that Wernicke encephalopathy results from severe acute deficiency of thiamine (vitamin B1), whilst Korsakoff's psychosis is a chronic neurologic sequela of Wernicke encephalopathy. This, however, is a clinical diagnosis and thiamine levels are not all that helpful.
Other vitamins (B12/folate, D3): have been associated with multiple psychiatric conditions but not typically useful for medical clearance from an emergency department.
RPR/syphilis screen: can be useful in first presentation of most neuropsychiatric complaints to rule out neurosyphilis. If not treated, 30% of patients may develop tertiary syphilis, where neurosyphilis is included. Neurosyphilis can present with a variety of psychiatric symptoms including mania, depression, psychosis and dementia.
HIV: screen at-risk populations. Can present as a variety of psychiatric symptoms.
Head imaging: options include CT-Head or MRI-Brain. Head imaging is clinically indicated in patients with altered mental status, head trauma (such as falls), focal neurologic deficits, new cognitive deficits, atypical psychiatric presentations (such as new onset psychosis outside of normal demographic range), and acute personality change. MRI less likely to be done in emergency department unless clear indication. Brain imaging for new onset psychosis is controversial as the % of patients with abnormal/treatment altering imaging findings is low. Still, some clinicians advocate for imaging at least once given the potential to dramatically influence disease course and prognosis. Evaluate for space-occupying lesions (tumors, AVM's, abscess, etc...), demyelinating disorders, stroke, or hemorrhage.
Very rarely ordered studies in the ED include:
Heavy metal screening: rarely indicated but can lead to altered mental status. The heavy metals most commonly associated with poisoning of humans are lead, mercury, arsenic and cadmium. Heavy metal poisoning may occur as a result of industrial exposure, air or water pollution, foods, medicines, improperly coated food containers, or the ingestion of lead-based paints.
Serum copper and cerulosplasmin: Wilson's disease (disorder of copper metabolism) is very rare, however can have neuropsychiatric manifestations to include psychosis. This was once considered routine part of first-break psychosis workup but is now no longer required and only sent when otherwise clinically indicated.
Paraneoplastic and encephalitis panels: one example includes anti-N-methyl-D-aspartate receptor (NR1) immunoglobulin antibodies which is an autoimmune encephalitis affecting predominantly young females. It is characterized with neuropsychiatric symptoms, including personality changes, psychosis, autonomic dysfunction, seizures and movement disorders. These labs are not routinely used given low diagnostic yield and clinical picture should fit a larger overall pattern than a single acute psychiatric presentation.
EEG (electroencephalogram): generally not necessary. Used to rule out seizure disorder if there is a history consistent with possible seizure activity. Often difficult to obtain in the ED. Also the yield of scalp leads may be lower in psychiatric presentations of epilepsy such as temporal or frontal lobe epilepsy.
CONCLUSION
I hope you enjoyed this overview of "medical clearance". Feel free to comment below if there is something I missed or if there was anything in particular that you learned. During our next lesson we will discuss how to perform a suicide risk assessment.
Resources for today's post include Pocket Psychiatry and the articles referenced in the lesson.
Bullet Psych is an Amazon Associate and we receive a small commission if you use our links.
Comments