American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations.

INTRODUCTION: The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed "medical clearance," often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs. METHODS: The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors. RESULTS: Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term "medical clearance," and the need for better science in this area. CONCLUSION: The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines.

INTRODUCTION: In the United States, the number of patients presenting to the emergency department (ED) for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial. Attempts have been made to establish a standard evaluation for these patients, but to date no nationally accepted standards exist. A task force of the American Association of Emergency Psychiatry, consisting of physicians from emergency medicine and psychiatry, and a psychologist was convened to form consensus recommendations on the medical evaluation of psychiatric patients presenting to EDs. METHODS: The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED (Part I) and then combined this with expert consensus (Part II). RESULTS: In Part I, we discuss terminological issues and existing evidence on medical exams and laboratory studies of psychiatric patients in the ED. CONCLUSION: Emergency physicians should work cooperatively with psychiatric receiving facilities to decrease unnecessary testing while increasing the quality of medical screening exams for psychiatric patients who present to EDs.

Medical evaluation and triage of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup.

Numerous medical and psychiatric conditions can cause agitation; some of these causes are life threatening. It is important to be able to differentiate between medical and nonmedical causes of agitation so that patients can receive appropriate and timely treatment. This article aims to educate all clinicians in nonmedical settings, such as mental health clinics, and medical settings on the differing levels of severity in agitation, basic triage, use of de-escalation, and factors, symptoms, and signs in determining whether a medical etiology is likely. Lastly, this article focuses on the medical workup of agitation when a medical etiology is suspected or when etiology is unclear.

A within-subject comparison of propofol and methohexital anesthesia for electroconvulsive therapy.

OBJECTIVES: The optimal anesthetic for electroconvulsive therapy (ECT) is a frequently studied but unresolved issue. Methohexital and propofol are 2 widely used anesthetic agents for ECT. The purpose of this study was to determine which of the 2 agents was associated with superior clinical outcomes. METHODS: Records from all patients who had undergone separate ECT courses with methohexital and propofol between 1992 and 2008 (n = 48) were reviewed for a retrospective within-subject comparison of outcome measures. The clinical outcomes we examined were number of treatments required in a course of ECT, changes in the Montgomery-Åsberg Depression Rating Scale and Mini Mental Status Examination, and length of stay in the hospital after initiation of ECT. Additionally, we compared treatment delivery between methohexital and propofol treatment courses, measuring rate of restimulation for brief seizures, seizure duration, percentage of treatments that were bilateral, and average charge administered. RESULTS: Data from 1314 treatments over 155 ECT courses were reviewed. Improvement in depressive symptoms, based on the Montgomery-Åsberg Depression Rating Scale, was not affected by choice of anesthetic agent. However, when right unilateral electrode placement was used, patients receiving propofol required significantly more treatments than those receiving methohexital. Propofol was also associated with a significantly higher requirement for bilateral ECT and higher stimulus dosing. Seizure duration was significantly shorter in the propofol condition, with more patients requiring restimulation for brief seizures. Length of stay in the hospital and cognitive outcomes were not significantly different between propofol and methohexital treatments. CONCLUSIONS: We recommend methohexital as the induction agent of choice for ECT, especially with right unilateral placement.

ECT in pregnancy: a review of the literature from 1941 to 2007.

OBJECTIVE: To review the literature on the use of electroconvulsive therapy (ECT) during pregnancy and to discuss its risks and benefits for treating severe mental illness during pregnancy. METHOD: PubMed and PsycINFO databases were searched for English or English-translated articles, case reports, letters, chapters, and Web sites providing original contributions and/or summarizing prior data on ECT administration during pregnancy. RESULTS: A total of 339 cases were found. The majority of patients were treated for depression and at least partial remission was reported in 78% of all cases where efficacy data were available. Among the 339 cases reviewed, there were 25 fetal or neonatal complications, but only 11 of these, which included two deaths, were likely related to ECT. There were 20 maternal complications reported and 18 were likely related to ECT. CONCLUSIONS: Although there are limited available data in the literature, it seems that ECT is an effective treatment for severe mental illness during pregnancy and that the risks to fetus and mother are low.

Arrhythmogenic right ventricular dysplasia.

Arrhythmogenic right ventricular dysplasia (ARVD) is a disorder in which normal myocardium is replaced by fibrofatty tissue. This disorder usually involves the right ventricle, but the left ventricle and septum also may be affected. Although the exact prevalence of ARVD is unknown, it is thought to occur in six per 10,000 persons in certain populations. After hypertrophic heart disease, it is the number one cause of sudden cardiac death in young persons, especially athletes. Patients with ARVD are usually men younger than 35 years who complain of chest pain or rapid heart rate. In some cases, sudden cardiac death is the first presentation. The initial diagnosis of ARVD is based on the presence of major and minor criteria established in 1994. Further confirmation of the diagnosis includes noninvasive studies, such as echocardiography and magnetic resonance imaging of the heart, and invasive studies such as ventricular angiography and endomyocardial biopsy. Patients with ARVD are treated initially with antiarrhythmic agents with serious consideration for automatic implantable cardioverter-defibrillator placement. In patients with persistent symptomatic arrhythmias, radiofrequency ablation, ventriculotomy, or even cardiac transplant may be necessary.