Decision Rule - King's College Criteria for Acetaminophen Toxicity

King’s College Criteria for Acetaminophen Toxicity

-Arterial pH <7.30  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [No/Yes]

-INR >6.5 (PT >100 seconds) . . . . . . . . . . . . . . . . . . . . . . . .  [No/Yes]

-Creatinine 3.4 mg/dL (300 µmol/L) . . . . . . . . . . . . . . . . . . . . [No/Yes]

-Grade III or IV hepatic encephalopathy  . . . . . . . . . . . . . . . .  [No/Yes]

The presence of any of the above should prompt referral and possible transfer to a center capable of liver transplantation.

Other predictors of a poor prognosis without transplant:

-Lactate >3.5 mmol/L after fluid resuscitation (<4 hours)  . . .  [No/Yes]

-Lactate >3 mmol/L after full fluid resuscitation (12 hours) . .  [No/Yes]

-Phosphate >3.75 mg/dL (1.2 mmol/L) at 48-96 hours . . . . .  [No/Yes]

https://www.mdcalc.com/kings-college-criteria-acetaminophen-toxicity

https://www.mdcalc.com/hepatic-encephalopathy-grades-stages

MDM - Suicidal Ideations (Discharge)

[##]-year-old [male/female] with [depression/suicidal ideations] with history and exam consistent with likely [presumptive diagnosis].

Initial consideration in this patient included major depressive disorder, adjustment disorder, suicide attempt (intentional overdose and self-injury amongst others), alcohol or other substance related mood disorders, and organic causes of altered mental status among others.

Patient presented to the ED [due to concerns over suicidal thoughts/after police were called due to suicidal comments/after his coworkers/supervisor noted suicidal comments].  On initial exam the patient was noted to be hemodynamically stable [with/without] evidence of intoxication.  Patient noted to have [no] evidence of [likely] self-injury [specify].  Labs [were/were not] ordered [and unremarkable as noted above/notable for elevated ethanol level without other evidence of overdose, illicit drugs or significant toxins].  The patient expressed [passive suicidal ideations/no suicidal ideations] in the ED [without/and no specific] plan [specify].

The patient was considered to be [low/moderate] risk for suicide based on consideration of risk factors, including [absence of suicidal plan/report of good social support].  Prior to discharge the patient [and family/bystanders] were questioned on access to firearms, which was [denied/planned for removal/secured].

The patient demonstrated a willingness to form a safety contract prior to discharge, as detailed in the discharge instructions below.  Return precautions for any concerns for safety were discussed, as well as follow up with [Mental Health] on [date] with the patient demonstrating understanding and agreement prior to discharge.

http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/
https://edsmartchart.blogspot.com/2020/06/physical-exam-psychiatric-mental-status.html
https://edsmartchart.blogspot.com/2020/06/discharge-instructions-contract-for.html

Discharge Instructions - Contract for Safety

Based on our clinical examination and testing, we feel that you are safe for discharge home today with the following precautions:

As discussed in the emergency department prior to discharge, you should be aware that worsening depression, thoughts of suicide with thoughts or images of specific plans, and behavior such as writing notes or giving away possessions are warning signs for risk of suicide.  If you experience these symptoms or have any concerns for your safety, you must return to the emergency department immediately, preferably by ambulance or with a friend or family member.

As discussed in the emergency department, you can attempt to distract yourself from depressive thoughts by engaging in healthy coping strategies, such as exercising, watching television or a movie, or contacting a friend, family member, or a chaplain or religious leader to talk.  You can obtain free and confidential support if you feel in distress or are having thoughts of suicide 24 hours a day 7 days a week by calling the National Suicide Prevention Hotline at 1-800-273-8255 or visit their website at https://suicidepreventionlifeline.org.  You can also communicate with someone via text message if you are in distress or have thoughts of suicide by texting “HOME” to 741741 (https://www.crisistextline.org) and you will be connected to a crisis counselor.

[Military-specific resources-You can also talk, text or online chat confidentially with a qualified responder, many of whom have military experience, by calling the Military Crisis Line at (<https://www.veteranscrisisline.net/ActiveDuty.aspx>).  You can also obtain additional information about available resources for coping with the stresses of military life at Military One Source (<http://www.militaryonesource.mil/>).]  

[The Trevor Project offers crisis intervention and suicide prevention to LGBTQ youth through its hotline, chat feature, and online support center.  You can call the Trevor Project to speak to a counsellor 24 hours a day 7 days a week at 1-866-488-7386.  You can also talk to a counsellor from The Trevor Project 24 hours a day 7 days a week by texting START to 678678.  You can chat with a counsellor from The Trevor Project by going to https://www.thetrevorproject.org/get-help-now/ and selecting the CHAT option in the upper right hand corner of the page.]

Please note that if your condition worsens or changes significantly, we would like to see you again.  You may return at any time if you have further concerns.  Following up with your primary care provider and/or specialist as indicated is important for your overall health and wellness.  As discussed in the emergency department prior to discharge, by signing these discharge instructions you are agreeing with this safety plan and agree to return if you have worsening thoughts of suicide or any other safety concerns.

Note: There are differing opinions on the utility of a safety contract in suicidal patients.  ACEP provides some templates for developing a safety contract and safety plan at this website: https://www.acep.org/patient-care/iCar2e/.

It will come down to provider preference whether you use this document as a safety contract, but there are resources where patients can obtain emergency counseling nationwide that are helpful to provide on discharge.

https://www.healthline.com/health/mental-health/suicide-resource-guide#4

Decision Rule - SAD PERSONS Score

SAD PERSONS Score:

-Sex = male [0 points/1 point]
-Age <19 or >45 years [0 points/1 point]
-Depressed symptoms [0 points/2 points]

-Past psychiatric history or suicide attempts [0 points/1 point]
-ETOH/drug use history [0 points/1 point]
-Rational thought loss [0 points/2 points]
-Separated, divorced or widowed or sickness with 3 or more prescription medications [0 points/1 point]
-Organized plan or serious attempt [0 points/2 points]
-No social support [0 points/1 point]
-Stated intent (or ambivalence) [0 points/2 points]

Note: This score was originally developed by Hockberger and Rothstein at the Harbor-UCLA Medical Center in 1988, as a scoring tool to predict the need for hospitalization in individuals at risk for suicide. After analysis of 119 patients, Hockberger and Rothsetin identified a score ≥ 6 as having a sensitivity of 94% and a specificity of 71% for predicting the need for psychiatry directed hospitalization (P<0.001).

This should not be used as your sole justification in determining someone does or doesn't need to be admitted.  This is most useful as a way of remembering suicidal risk factors, and for making a case in documentation for admission.  It is especially helpful for newer students and residents to remember and organize the questions they will ask as part of medical clearance of a suicidal patient.  It is included as a "Decision Rule" for ease of organizing it as a template on this site, even though it does not perfectly fit that description.

http://www.emdocs.net/emergency-department-tips-tricks-managing-suicidal-patient/

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MDM - Suicidal Ideations (Admit)

[##]-year-old [male/female] with [depression/suicidal ideations] with history and exam consistent with likely [presumptive diagnosis].

Initial consideration in this patient included major depressive disorder, adjustment disorder, suicide attempt (intentional overdose and self-injury amongst others), alcohol or other substance related mood disorders, and organic causes of altered mental status among others.

Patient presented to the ED [due to concerns over suicidal thoughts/after police were called due to suicidal comments/after his coworkers/supervisor noted suicidal comments].  On initial exam the patient was noted to be hemodynamically stable [with/without] evidence of intoxication.  Patient noted to have [no] evidence of [likely] self-injury [specify].  Labs [were/were not] ordered [and unremarkable as noted above/notable for elevated ethanol level without other evidence of overdose, illicit drugs or significant toxins].  The patient expressed [passive suicidal ideations/no suicidal ideations] in the ED [with/without] plan [specify].

Patient medically cleared based on history, exam, and workup as noted above with no evidence of significant medical instability or medical condition causing or contributing to psychiatric condition at this time.  The patient was considered to be [moderate/high] risk for suicide based on consideration of risk factors, including [access to a firearm/suicidal plan involving lethal means/poor access to outpatient care or social support/unwillingness to safety contract in the ED/a SAD PERSONS score of ## points consistent with high risk]. 

Patient was evaluated by [mental health provider name] who agreed with need for admission.  Concerns for safety and plan for admission were discussed with the patient, who is [voluntary/involuntary] with plan for admission at this time.

http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/
https://edsmartchart.blogspot.com/2020/06/physical-exam-psychiatric-mental-status.html
https://edsmartchart.blogspot.com/2020/06/decision-rule-sad-persons-score.html

Physical Exam - Psychiatric Mental Status Exam

The patient’s mood [how the patient tells you they’re feeling-is described as anxious/depressed/crawling out of their skin/etc.].  The patient’s affect [what you observe-appears anxious/depressed/flattened/blunted/restricted/exaggerated] which is [congruent/incongruent] with their reported mood.  Patient noted to be [making good/poor eye contact/frequently looking down/away].  Patient [was/was not] noted to be attending to internal stimuli [specify/with patient noted to be conversing in an empty room/etc.].  The patient’s thought process is noted to be [organized/disorganized with/without delusions/obsessions].  The patient’s speech [is noted to be unremarkable/notable for pressured speech/inappropriately loud/soft given size of the room and distance apart/tangential speech/etc.].  The patient was noted to be [well kempt and groomed/disheveled/encrusted with urine and feces].  

The patient was noted to be expressing [suicidal thoughts with/without reported plan/no suicidal or homicidal thoughts or plan at this time].  The patient [reported/denied] hallucinations [described as auditory/visual].

https://www.hippoed.com/em/ercast/episode/march2017/examiningmental