ADOLESCENT EMERGENCIES

ANITA ROBINSON, M.D.

ADOLESCENTEMERGENCIES
Suicide Drug Intoxication Pregnancy rape

Suicide Background
Third leading cause of death for teens and young adults Persons more likely to commit suicide -Older adolescents -Males (4x more than females) Persons more likely to attempt suicide -females

Etiology and Pathogenesis

Normal stresses of adolescence -Biological -Psychological -Social/environmental Societys view of adolescence Role of socioeconomic factors

Etiology of Suicide Attempt

Predisposing factors Vulnerable = Adolescent ^ Acute Stressors Suicide Attempt

Predisposing Factors
Abuse Physical/Sexual Chronic Diseases Chronic substance abuse, teen/parent Family disorganization Poor school performance Family hx of suicide Age/ firearm in the house

Predisposing Factors (cont.)

Recent behavioral changes Feeling of.HALERS Psychiatric illness ADHD Affective Disorder Conduct/ Anxiety Disorder Depression

Acute Stressors
Early/Late psychological maturation Sexuality Anxiety about beginning sex homosexuality pregnancy Death of someone close Recent loss (person/relationship)

Acute Stressors (cont.)

Changes in school performance Victimization, assault,rape Substance use experimentation Major changes in social environment Onset of psychiatric disorder Media

Vulnerable Adolescent
Late adolescent Depression Low self esteem coupled with multiple failures Not fitting in, no friends

Signs of suicide
Changes eating/sleeping habits Withdrawal Chronic drug use Frequent somatic complaints Giving away favorite possessions Feelings of hopelessness,guilt,poor concentration,boredom,school grade drop

Case
Jessie is a 17 y.o. female who you are seeing in the ER at 4PM on a Saturday afternoon. She presents with a known Tylenol overdose earlier that day. She s somewhat drowsy, but is coming to and able to answer basic questions. She is medically stable. Her mother comes with the Tylenol bottle and states that it was recently brought and that

Case (cont.)
10 pills were missing (325mg each). After 4 hours, Tylenol levels are in a safe zone, and you have to determine her disposition. What specific points from the hx are important to ask Jessie? What criteria should you use to hospitalize?

Risk Assessment Factors

Low Moderate High

Factor
PRECIPATATING EVENT LOW, argument with friend, teacher MODERATE, fight with close friend,school failure,difficult home situation HIGH, break-up important relationship,thrown out of home,pregnancy discovery,death close relationship,thinking disorder,hallucinations

FACTOR
INTENDED PURPOSE LOW, unknown, impulsive MODERATE, attention seeking, to punish,escape,cannot face shame or failure HIGH,to be dead, no purpose in living, to join deceased one

FACTOR
PLAN - PERCEIVED LETHALITY LOW, small amount of pills, perceived low toxicity MODERATE,small amount of pills,perceived as toxic, slash wrist HIGH, violent method, large amount of pills, perceived toxic

FACTOR
PLAN REAL LEATHALITY LOW, relative innocuous MODERATE.moderately harmful but perceived recovery HIGH, significant potential for death

FACTOR
PLAN SPECIFICITY LOW,no solid plan MODERATE, specific plan, not rehearsed,several plans, method readily available HIGH, one method chosen and steps in place, may have rehearsed plan

FACTOR
PLAN - DISCOVERY POTENTIAL LOW,announces intent, someone at home MODERATE, someone expected at home, calls someone, location highly visible HIGH, isolated location or situation,tells no one

FACTOR
LIFE STRESSORS CURRENT LOW, none MODERATE, environmental changes, physical changes, failure to achieve HIGH, death of close individual, thrown out of home, rejection by boyfriend

FACTOR
MOOD - AFFECT BEHAVIOR LOW, optimistic, able to verbalize MODERATE, depressed,but mood lightens,few friends HIGH, flat, distant affect, no friends, no change in mood after talking

FACTOR
PAST COPING AND MENTAL HEALTH LQW, good coping and support, no mental health issues MODERATE, distorts reality, impulsive, uses peers for support, some depression,mood swings HIGH. loose reality,victim of fate,depressed

FACTOR
FAMILY STRUCTURE FUTURE PLANS LOW, supportive, good coping.,definite future goals MODERATE, overburden family but tries to be supportive,wants to be somebody but no plans HIGH, overburden family,no coping,no plans, alienated

SUMMARY
PRECIPITATING EVENT INTENDED PURPOSE PLAN METHOD-PRECEIVED LETHALITY REAL LETHALITY SPECIFICITY DISCOVERY POTENTIAL

SUMMARY (cont.)
LFE STRESSORS CURRENT MOOD AFFECT BEHAVIOR PAST COPING AND MENTAL HEALTH FAMILY STRUCTURE/FUTURE PLANS

DRUG EFFECTS
THERAPEUTIC INTOXICATION OVERDOSE WITHDRAWAL

DRUGS OF ABUSE
Illicit and nonillicit Combination of both Alcohol, #1 followed by smoking cigarettes and marijuana Rise in stimulant use Inhalant use popular with early adolescents Cocaine, opiate, and othe drug use stable

CLASSES OF DRUGS
Opioids Depressants type 1 Stimulants Sedatives,hypnotics Depressants type2 Inhalants Depressants type 3 Hallucinogens Marijuana Phencyclidine - PCP

CASE
Ann is a 17 y.o. who present in your clinic with a 2 day hx of cough, rhinorhea, sore throat, and generalized muscle aches. She also has had abdominal pain with vomiting and diarrhea. Her temp is normal and pulse slightly elevated. She appears agitated. Her P.E. is normal except for dilated pupils.

OPIOID CLASS
Morphine Heroin Codeine Oxycodone and hydromorphone Merperedine and methodone Talwin, darvon, ultram Nsaids

OPIOID SYMPTOMS
V.S. depressed Mental Status euphoria, stupor Physical miosis, decreased reflexes, analgesia,amnesia, constipation, pulmonary edema, respiratory depression and coma

OPIOID WITHDRAWAL
V>S> - rapid pulse Mental status anxious, paranoid Physical mydriasis, flu like symptoms, abdominal pain, increased reflexes

STIMULANT/ANTICHOLINER GIC SYMPTOMS

V>S> - increased Mental status euphoria, anxious Physical mydriasis,reflexes increased, arrythmia,increased muscle tone, seizures, pulmonary edema, coma

STIMULANT CLASS
Cocaine Amphetamines (designer drugs) Ritalin Caffeine, nicotine

STIMULANT WITHDRAWAL
V.S. depressed Mental status severe depression and paranoid state, suicide high Physical decreased reflexes, marked fatigue,difficult to awake,constipation

SEDATIVE/HYPNOTIC
Alcohol Benzodiazepine Barbiturates SSRI Tricyclic antidepressants Anticonvulsants

SEDATIVE/HYPNOTIC SYMPTOMS
V.S. decreased Mental status euphoria, stupor Physical marked respiratory depression, slurred speech, staggering gait, decreased reflexes,nystagmus, seizures, arrythmis. coma

FLUMAZENIL
Benzodiazepine antidote Use with caution May cause vomiting May not totally reverse respiratory depress. Seizures in physical dependence and mixed overdoses Arrythmia with tricyclics and mixed overdoses

INHALANTS
Aromatic and aliphatic types Benzene, moth balls kerosene, gasoline Airplane glue, correction fluid Amyl nitrate, butyl nitrate, nitrous oxide Feon

INHALANT SYMPTOMS
V.S. decreased Mental status euphoria, stupor Physical respiratory depression, hypoxia,,arrythmia, renal and muscle damage, coma

HALLUCINOGENS
Lsd Mescaline Pilocybin,, peyote cactus Mushrooms Nutmeg Ergots

HALLUCINOGEN SYMPTOMS
V.S. increased Mental status euphoria with hallucinations Physical impaired senses,synesthesia, sweating, dilated pupils,palpitations,tremors and poor coordination

PHENYCYCLIDINE
PCP V.S. may be normal, increased B.P. ,temp, Mental status confusion, anxiety, amnesia Physical vertical nystgmus,and may see horizontal or rotary, muscle rigidity. Catatonia,ataxia,sweating, extreme muscle strength, seizures

PREGNANCY - DIAGNOSIS
LABORATORY Urine HCG- + 7-10 days after conception severe renal damage interferes Serum HCG- + 6-12 days after ovulation peaks 10-12 weeks

PREGNANCY-PHYSICAL EXAM
Always perform pelvic exam,including GC/CHL Bimanual exam Less than 12 weeks enlarged globularr uterus below the symphysis pubis 16 weeks midway umbilicus/pubic bone 20 weeks umbilicus

PREGNANCY PSYCHOSOCIAL
Concrete vs. abstract thinking Sexual history Parental knowledge Ability to communicate with parents Partner awareness and what pt. Wants to do Pregnancy outcome options Support status and safety to go home

RAPE
Under age 18 and less than 72 hours rape kit,, family advocacy, commanding officer,Dr. Craigs group Over age 18 and less than 72 hours,above but refer to SAVI, Cindy Stewart, 202 6851171,for navy family advocacy other branches

RAPE
Under age 18 and greater than 72 hours,do standard STD work up,HEADDS, family advocacy central contact Jackie Richardson, 202 685-1182 or county rape crisis center Over age 18 and greater than 72 hours, work up as above but refer to SAVI, contact Cindy Stewart 202 685-1171

STATUTORY RAPE
DC law, sexual acts or sexual contact between a child under 16 and any person four or more years older. Maryland, Sexual contact with another person who is under 14 and the person performing the sexual contact is four or more years older than the victim or.

STATUTORY RAPE (cont.)

A sexual act with another person who is 14 or 15 years of age and the person performing the act is at least 21 years of age Or, vaginal intercourse with another person who is 14 or 15 years of age and the person performing the act is at least 21 years of age

STATUTORY RAPE
VIRGINIA Carnal knowledge of a child younger than 13 is automatically considered to be rape and falls under the code of Virginia 18.2-61 An adult over age 17 who has sex with a child over age 14, but under age 18, can be guilty of contributing to the delinquency of a minor