# Clinical Cases: Psychiatric Emergencies

## Case 1: Acute Suicidal Crisis

### Patient Demographics
- **Age:** 19 years old
- **Sex:** Male
- **Occupation:** College freshman

### Chief Complaint
Per roommate: "He texted me that he's thinking about ending it all. I'm bringing him in."

### History of Present Illness
The patient is a 19-year-old male brought to the emergency department by his roommate after sending a text message stating "I can't do this anymore. I've been thinking about jumping off the parking garage. Everyone would be better off without me." The roommate found him in his dorm room, tearful, holding a bottle of acetaminophen.

The patient admits to the text and states he has been having suicidal thoughts for the past 2 weeks that have intensified over the past 3 days. He describes a specific plan to jump from the campus parking structure. He has scouted the location twice. He states he feels hopeless about his future after failing two midterms and being placed on academic probation. His girlfriend of 2 years broke up with him last week, saying he was "too depressing to be around."

He has been isolating himself, skipping classes, not eating, and sleeping 14-16 hours daily. He wrote a note to his parents but has not sent it yet. He denied taking any pills; he says the roommate arrived before he could.

He has no prior psychiatric history. He denies prior suicide attempts. He drinks alcohol heavily on weekends (8-10 drinks) but denies current intoxication. He denies drug use. No family history of suicide.

### Mental Status Examination

**Appearance:** Disheveled, unshaven, tearful young man in wrinkled clothing

**Behavior:** Cooperative but withdrawn; poor eye contact; psychomotor retardation

**Speech:** Slow rate, soft volume, increased latency

**Mood:** "Worthless... hopeless"

**Affect:** Depressed, constricted, hopeless quality

**Thought Process:** Linear, impoverished, ruminative

**Thought Content:**
- Active suicidal ideation with specific plan (jumping)
- Has scouted location (preparatory behavior)
- Intent: "I was going to do it tonight"
- Access to lethal means: High location accessible
- Wrote note (preparing affairs)
- Hopelessness: "Nothing will ever get better"
- Worthlessness: "Everyone is better without me"
- No homicidal ideation

**Perceptions:** No hallucinations

**Cognition:** Alert, oriented x3; concentration impaired

**Insight:** Limited - believes suicide is the only solution

**Judgment:** Severely impaired

### Risk Assessment

**Risk Factors:**
- Active suicidal ideation with specific plan
- Preparatory behaviors (scouting location, writing note, acquiring pills)
- Expressed intent
- Male sex
- Access to lethal means
- Recent losses (relationship, academic standing)
- Hopelessness
- Social isolation
- Heavy alcohol use
- Age (college students at elevated risk)
- No current treatment

**Protective Factors:**
- No prior attempts
- Roommate involvement (help-seeking by proxy)
- No psychotic symptoms
- No family history of suicide
- Expressed some ambivalence ("I was going to do it" suggests did not)

**Risk Stratification: HIGH/IMMINENT**
- Active ideation with plan, intent, means access
- Preparatory behaviors
- Recent acute stressors
- Multiple risk factors with limited protective factors

### Immediate Management

**1. Ensure Safety:**
- Constant 1:1 observation (cannot be left alone)
- Secure environment: Remove all potential ligature points, sharps, medications
- Search belongings for means
- Patient in hospital gown

**2. Medical Stabilization:**
- Serum acetaminophen level: Negative (did not ingest)
- Alcohol level: Negative
- Urine drug screen: Negative
- Basic metabolic panel: Normal

**3. Collateral Information:**
- Roommate: Confirms 2-week decline, increasing isolation
- Parents (contacted with patient consent): Unaware of any problems, supportive
- No prior psychiatric treatment

**4. Document Risk Assessment:**
- All risk factors identified
- All protective factors identified
- Interventions taken
- Rationale for disposition

### Disposition

**Criteria for Psychiatric Hospitalization - MET:**
- Imminent danger to self
- Unable to contract for safety
- Requires supervised setting for stabilization
- Does not have adequate outpatient support structure

**Admission Type:**
- Voluntary admission preferred if patient agrees
- Patient initially ambivalent but agreed to voluntary admission after discussion
- If refused, would meet criteria for involuntary hold (danger to self)

### Inpatient Treatment Plan

**Safety:**
- 1:1 observation initially
- Unit precautions (sharps, ligature)
- Daily reassessment of suicide risk
- Transition to 15-minute checks when clinically appropriate

**Diagnostic Assessment:**
- Provisional diagnosis: Major Depressive Disorder, Single Episode, Severe
- Rule out Alcohol Use Disorder

**Pharmacotherapy:**
- Start sertraline 50 mg daily for depression
- Monitor for activation/worsening suicidal ideation (Black Box Warning)
- PRN hydroxyzine 25 mg for anxiety

**Psychotherapy:**
- Daily supportive therapy
- Safety planning (to complete before discharge)
- Cognitive interventions for hopelessness

**Discharge Planning (to begin early):**
- Contact university counseling center
- Outpatient psychiatry appointment
- Family involvement
- Means restriction (campus parking structure access)
- Medical withdrawal from semester if needed

---

## Case 2: Acute Agitation with Unknown Etiology

### Patient Demographics
- **Age:** 35 years old
- **Sex:** Male
- **Occupation:** Unknown

### Chief Complaint
Per EMS: "Found in the street yelling at cars. Very agitated, combative."

### History of Present Illness
The patient is a 35-year-old man brought by EMS after being found in the middle of a busy street at 2 AM, yelling incoherently at passing cars. Bystanders called 911 when he began throwing objects at vehicles. EMS reports he was combative and required restraint for transport. He is unable to provide coherent history.

Witnesses report he appeared to be talking to someone who wasn't there. No identification on his person. No collateral available. No known medical or psychiatric history.

### Initial Presentation

**Vital Signs:**
- Temperature: 101.4°F (38.6°C)
- Heart rate: 128 bpm
- Blood pressure: 168/102 mmHg
- Respiratory rate: 22
- O2 saturation: 96% on room air
- Pupils: 6 mm bilaterally, reactive

**Physical Examination:**
- General: Agitated, diaphoretic, combative
- Skin: Flushed, diaphoretic, no track marks visible
- Neuro: Moving all extremities, grossly non-focal (limited exam)
- Unable to complete detailed exam due to agitation

### Mental Status Examination (Limited)

**Appearance:** Disheveled, flushed, diaphoretic

**Behavior:** Severely agitated, yelling, striking at staff, requires multiple security officers

**Speech:** Loud, pressured, incoherent

**Mood:** Unable to assess

**Affect:** Agitated, labile, fearful

**Thought Process:** Disorganized, incoherent

**Thought Content:** Appears paranoid (yelling "get away from me"), unable to assess formally

**Perceptions:** Appears to respond to internal stimuli (talking to someone not present, looking at empty space)

**Cognition:** Unable to assess - not cooperative; appears disoriented

### Differential Diagnosis

**Medical Causes (Must Rule Out First):**
- Substance intoxication (stimulants, PCP, synthetic cannabinoids, anticholinergics)
- Substance withdrawal (alcohol, benzodiazepines)
- Delirium (infection, metabolic, CNS pathology)
- Hypoglycemia
- Hyperthyroidism/thyroid storm
- Seizure/postictal state
- Meningitis/encephalitis
- Intracranial pathology (hemorrhage, mass, trauma)

**Psychiatric Causes:**
- Acute psychotic episode (schizophrenia, brief psychotic disorder)
- Manic episode with psychosis
- Severe anxiety/panic

### Immediate Management

**1. Safety and De-escalation Attempt:**
- Multiple staff present (show of force)
- Attempt verbal de-escalation: "We're here to help you. You're safe. Can you tell us what's going on?"
- Patient remains combative, non-redirectable

**2. Pharmacological Management (verbal de-escalation failed):**
- Given agitation with unknown etiology, avoid antipsychotics initially (could worsen underlying condition)
- Lorazepam 2 mg IM given for sedation
- Patient somewhat calmer after 20 minutes, still agitated

**3. Diagnostic Workup:**
- Labs ordered STAT:
  - Glucose: 94 mg/dL (normal - rules out hypoglycemia)
  - CBC: WBC 14.2 (elevated)
  - CMP: Normal
  - Urine drug screen: Positive for amphetamines
  - Blood alcohol: Negative
  - TSH: Normal
  - Ammonia: Normal
- CT Head without contrast: No acute intracranial abnormality
- Urinalysis: Normal
- Chest X-ray: Normal

**4. After Results - Updated Assessment:**

**Positive amphetamines on UDS suggests:**
- Methamphetamine intoxication
- Prescription amphetamine (Adderall) intoxication
- Synthetic cathinones ("bath salts") - may not show on standard screen

**Clinical Picture Consistent with Stimulant Intoxication:**
- Agitation
- Tachycardia
- Hypertension
- Hyperthermia
- Mydriasis
- Paranoia
- Possible tactile hallucinations
- Diaphoresis

### Revised Treatment Plan

**Stimulant Intoxication Management:**

**1. Supportive Care:**
- Quiet, low-stimulation environment
- IV access, fluids for dehydration
- Cooling measures for hyperthermia

**2. Benzodiazepines (first-line for stimulant-induced agitation):**
- Lorazepam 2 mg IM/IV every 30-60 minutes PRN
- Addresses agitation, reduces cardiovascular strain, lowers seizure risk
- More effective than antipsychotics for stimulant agitation

**3. Avoid:**
- Antipsychotics as first-line (can worsen hyperthermia, lower seizure threshold)
- Physical restraints if possible (increase hyperthermia, rhabdomyolysis risk)
- Beta-blockers (risk of unopposed alpha-agonism)

**4. Monitoring:**
- Continuous cardiac monitoring
- Temperature every 30 minutes
- Watch for:
  - Seizures
  - Rhabdomyolysis (check CK if persistent hyperthermia)
  - Cardiac arrhythmias

### Hospital Course

**2 hours post-presentation:**
- Total lorazepam 6 mg IM
- Temperature 99.8°F (improving)
- HR 98, BP 148/88
- Calmer, able to answer questions

**Updated History (when able to communicate):**
- States he used "crystal" (methamphetamine) approximately 12 hours ago
- Has been bingeing for 3 days with minimal sleep
- Chronic methamphetamine use disorder
- No psychiatric history when not using
- Experienced "shadow people" (meth-induced hallucinations)

**Diagnosis:**
- Amphetamine-type Substance Intoxication, Severe (F15.129)
- Amphetamine-type Stimulant Use Disorder, Severe (F15.20)

**Disposition:**
- Psychiatry observation overnight for resolution of intoxication
- Repeat mental status exam when sober
- Substance use treatment referral
- If psychosis resolves completely with sobriety, likely substance-induced rather than primary psychotic disorder

---

## Case 3: Neuroleptic Malignant Syndrome

### Patient Demographics
- **Age:** 28 years old
- **Sex:** Male
- **Occupation:** Unemployed

### Chief Complaint
Per group home staff: "He's confused, stiff, and has a high fever. His medication was just increased."

### History of Present Illness
The patient is a 28-year-old man with schizophrenia who was recently discharged from inpatient psychiatry 5 days ago. During hospitalization, his haloperidol was increased from 10 mg to 20 mg daily due to persistent psychosis. He was also started on haloperidol decanoate 100 mg IM at discharge for maintenance.

Group home staff report that over the past 2 days, he has become increasingly confused and "not himself." Today, he was found in his room, rigid, barely responsive, and soaking wet with sweat. They took his temperature and found it to be 104.2°F.

### Medication History
- Haloperidol 20 mg daily (increased 7 days ago)
- Haloperidol decanoate 100 mg IM (5 days ago)
- Benztropine 2 mg BID

### Physical Examination

**Vital Signs:**
- Temperature: 104.8°F (40.4°C)
- Heart rate: 124 bpm
- Blood pressure: 168/110 mmHg (fluctuating, was 92/58 earlier)
- Respiratory rate: 24
- O2 saturation: 94% on room air

**General:** Diaphoretic, ill-appearing, minimal responsiveness

**HEENT:** Drooling, dry mucous membranes

**Cardiovascular:** Tachycardia, regular rhythm

**Pulmonary:** Clear, tachypneic

**Neurological:**
- **Level of consciousness:** Obtunded, responds minimally to voice, withdraws to pain
- **Motor:** Severe generalized "lead-pipe" rigidity throughout all extremities
- **Tremor:** Coarse tremor superimposed on rigidity
- **Reflexes:** Increased throughout
- **Other:** Mutism

### Laboratory Studies

**STAT Labs:**
- WBC: 18,400 (elevated)
- Creatine kinase (CK): 12,840 IU/L (massively elevated; normal <200)
- BUN: 42 (elevated)
- Creatinine: 2.1 (elevated from baseline 0.9)
- AST: 186, ALT: 124 (elevated)
- Sodium: 148 (elevated)
- Myoglobin: Elevated
- Lactate: 3.8 (elevated)
- UA: Brown, positive for blood (no RBCs) - myoglobinuria

**ECG:** Sinus tachycardia, QTc 460 ms

### Diagnosis

**Neuroleptic Malignant Syndrome (NMS) (G21.0)**

**Cardinal Features - All Present:**
1. **Hyperthermia:** 104.8°F
2. **Severe muscular rigidity:** Lead-pipe rigidity
3. **Autonomic instability:** Tachycardia, labile BP, diaphoresis
4. **Altered mental status:** Obtundation, confusion

**Supporting Features:**
- Recent antipsychotic dose increase
- Elevated CK (rhabdomyolysis)
- Leukocytosis
- Acute kidney injury (from rhabdomyolysis)
- Elevated liver enzymes

**Precipitating Factors:**
- Recent haloperidol dose increase
- High-potency antipsychotic
- IM depot formulation (prolongs exposure)
- Rapid dose titration

### Differential Diagnosis

**Must Rule Out:**
- Serotonin syndrome (different features - clonus, hyperreflexia, GI symptoms; different med history)
- Malignant hyperthermia (occurs with anesthetics)
- Lethal catatonia (may be difficult to distinguish)
- CNS infection (meningitis/encephalitis)
- Heatstroke
- Sepsis

**Distinguishing NMS from Serotonin Syndrome:**

| Feature | NMS | Serotonin Syndrome |
|---------|-----|-------------------|
| Onset | Days | Hours |
| Rigidity | Severe, lead-pipe | May have rigidity, but clonus predominates |
| Reflexes | Normal to increased | Hyperreflexia |
| Clonus | Absent | Present |
| GI symptoms | Absent | Nausea, vomiting, diarrhea |
| Medication | Dopamine blockers | Serotonergic agents |

### Emergency Management

**1. STOP ALL ANTIPSYCHOTICS IMMEDIATELY:**
- Discontinue haloperidol (cannot reverse depot, but stop oral)
- Stop benztropine (anticholinergic may worsen)
- Alert: Long-acting injectable will continue to release drug for weeks

**2. Supportive Care - ICU Admission:**
- Aggressive IV fluid resuscitation (protect kidneys from myoglobin)
- Target urine output >200 mL/hour
- Cooling measures: Cooling blankets, ice packs, cooled IV fluids
- Continuous monitoring: Temperature, cardiac, BP
- Intubation if respiratory compromise

**3. Specific Treatments:**

**Dantrolene:**
- Skeletal muscle relaxant (blocks calcium release from sarcoplasmic reticulum)
- Dose: 1-2.5 mg/kg IV, may repeat to max 10 mg/kg/day
- Indicated for severe hyperthermia and rigidity
- Started in this patient: Dantrolene 2 mg/kg IV

**Bromocriptine:**
- Dopamine agonist (counteracts dopamine blockade)
- Dose: 2.5-5 mg PO/NG TID
- Started in this patient: Bromocriptine 2.5 mg via NG tube TID

**Benzodiazepines:**
- For muscle relaxation and agitation
- Lorazepam 1-2 mg IV q6h

**4. Monitoring:**
- CK every 6 hours (trending for rhabdomyolysis)
- Renal function daily (AKI risk)
- Temperature every 1 hour
- Continuous cardiac monitoring
- Watch for compartment syndrome (from rigidity)
- Watch for DIC

### Hospital Course

**Day 1-2:**
- Temperature slowly decreasing with dantrolene and cooling
- CK peaked at 24,000, then began trending down
- Required 8L IV fluids to maintain urine output
- Creatinine peaked at 2.8, then improved

**Day 3:**
- Temperature normalized
- Rigidity improving
- More alert, following commands
- CK 4,200 and trending down

**Day 7:**
- Mental status at baseline
- CK normalized
- Renal function normalized
- Dantrolene and bromocriptine tapered

### Discharge Planning

**Antipsychotic Rechallenge Considerations:**
- Wait at least 2 weeks after NMS resolution
- Choose low-potency or second-generation agent
- Start at low dose, titrate slowly
- Clozapine has lowest NMS risk
- Close monitoring
- 30% recurrence risk with rechallenge

**Documentation:**
- NMS documented in medical record as adverse reaction
- Alert in electronic system
- Patient and family education about symptoms of NMS
- Medical alert bracelet recommended

---

## Image Attribution

![Psychiatric Emergency Assessment Flowchart](case_01_image.jpg)

*Image: Clinical flowchart for psychiatric emergency assessment including suicide risk stratification, agitation management algorithm, and NMS diagnostic criteria. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.*