Restraints should be used in the ED to manage aggression, or any patient with a behavioral emergency, only when all other less-restrictive means have been exhausted. In 2007 the Centers for Medicare and Medicaid Services (CMS) revised the conditions of participation for all acute hospitals and now require that the patient rights explicitly include the “right to be free of restraint.” The CMS definition of restraint is “any means to restrict movement of a patient.” In this revision the restraint application training and management required in behavioral health units is required for all acute hospitals. Demonstration of annual physical restraint training is now mandated, and specifics related to restraint use and patient management must be described. Any hospital death of a patient in restraints or who has been in restraint within the past 24 hours must be reported as a sentinel event and reported directly to the regional offices of CMS. States that also provide requirements for hospital licensing may have additional requirements related to restraint use. Use of a sitter in the ED may also be considered “restraint” and is subject to CMS rules as well. Reasons for restraints or seclusion should be documented and include immediate threat to life and failure of less-restrictive methods. Orders must be time specific: “restraint is needed” or “restraint is needed for duration of visit” is not an acceptable order. Once a patient is in restraints, safety and well-being must be assessed every 15 minutes and documented.

The most striking physical attribute in patients with moderate to severe anorexia is their cachectic appearance. Physical examination may reveal hypothermia, peripheral edema, and thinning hair. ⁹ Behaviorally, these patients have a flat affect and display psychomotor alterations. Physical and behavioral symptoms also occur in other conditions, so it is important to rule out potentially treatable causes.

A complete blood count (CBC) may reveal normocytic, normochromic anemia resulting from bone marrow suppression from starvation. Serum chemistry determinations often indicate varying degrees of hypokalemia from laxative abuse. In addition, dehydration can cause significant electrolyte abnormalities, including hyponatremia. Hypocalcemia from dietary deficiency of calcium and associated protein deficiency also occur. β-Human chorionic gonadotropin can determine whether pregnancy is the cause of vomiting and electrolyte abnormalities. Urinalysis is used to rule out urinary tract infections, dehydration, or renal acidosis. Positive fecal occult blood suggests esophagitis, gastritis, or repetitive colonic trauma from laxative abuse and a bleeding disorder or severe protein malnutrition. Serum erythrocyte sedimentation rate and thyroid function tests are unlikely to alter ED management but may be ordered to rule out inflammatory or endocrine pathologic processes.

Care in the ED may include rehydration, correction of electrolyte abnormalities, and appropriate referral for continuing medical and psychiatric treatment. ¹² Consultations with psychiatry and adolescent medicine specialists are recommended for inpatient care and to facilitate outpatient follow-up care.

No specific medications have been shown to alleviate the disordered body image characteristic of anorexia. For nutritional therapy, forced feedings with total parenteral nutrition or tube feedings may be used to replace nutrients, stabilize nutrient deficiency syndromes, and alter mood when the patient becomes nutritionally replenished.

Anxiety in its most severe form can be quite debilitating. The condition is categorized as mild, moderate, severe, or panic disorder. Organic illness, medications, drug abuse, and obvious psychotic causes of an anxious state must be ruled out and documented before treatment of anxiety. Patients require ED treatment for anxiety when they are in such an acutely anxious state that they pose a danger to themselves and others. A thorough medical and psychiatric history is critical. Documentation should include any changes in behavior and somatic symptoms such as headaches, dizziness, disorientation, confusion, and syncope. Family and significant others are reliable sources of history for the patient with acute anxiety. Previous psychiatric illnesses and any current medical problems should be documented. Identify any agents that can cause anxiety (e.g., caffeine, nicotine, prescribed drugs, over-the-counter medications, illicit drugs, alcohol). Thorough physical assessment is required to identify potential life-threatening illnesses. The clinician should focus on signs and symptoms of anxiety; however, organic causes should be eliminated first. Diagnostic studies are used to rule out physical causes of anxiety such as metabolic disorders. Needle marks indicate illicit drug involvement, whereas hepatomegaly, ascites, and spider angioma suggest alcohol abuse.

A patient with anxiety may present as a classic panic attack, which is characterized by sudden onset of fear and a sense of impending doom with at least four of the following symptoms—palpitations, diaphoresis, tremulousness, shortness of breath, chest pain, dizziness, nausea, abdominal discomfort, fear of injury or going crazy, derealization (perception of altered reality), and depersonalization (perception that one’s body is surreal). Evaluation of mental status can be especially helpful in distinguishing functional disorders from organic disorders. Assessment should include the following:

Anxiety states are associated with increased prevalence of other physical illnesses. Avoid falsely attributing somatic symptoms of anxiety to other medical conditions.

Laboratory tests to rule out physical illness include a CBC with differential, serum chemistry profile, pregnancy test, and serum or urine screens for drugs. Specific serum endocrine panels are also available to diagnose illnesses such as hyperthyroidism. Cardiopulmonary disorders such as pneumonia, congestive heart failure, and pneumothorax can be ruled out through physical assessment and a chest x-ray examination. An ECG can identify tachydysrhythmias and myocardial infarction as the cause of palpitations and other symptoms.

Acute anxiety has been effectively treated with the passage of time, social support, and a short course of fast-acting anxiolytics, preferably a benzodiazepine (Table 51-2). ²⁰ In chronic anxiety psychotherapy anxiolytics are the recommended course. Chronic anxiety often requires a comprehensive approach using psychotherapy, counseling, and a wider spectrum of anxiolytics (e.g., benzodiazepines, buspirone, antidepressants). Short-acting benzodiazepines in parenteral form are most useful for acute treatment. Benzodiazepines should be prescribed only in motivated and cooperative individuals with reliable follow-up arrangements. β-Blockers do not reduce intrinsic anxiety but may be beneficial in treatment of associated tachycardia. Buspirone may be initiated in the ED after consultation with a psychiatrist or the patient’s primary care physician. Antidepressants have well-known pharmacologic profiles and could be useful in the patient with concomitant depression and anxiety. ²³ They have demonstrated benefit as adjunct agents in the treatment of generalized anxiety disorder. Antidepressants have been relegated to long-term outpatient use for other chronic anxiety disorders.

Anxiety disorders are often chronic illnesses and require follow-up psychiatric intervention for successful treatment. Any patient with anxiety who presents with suicidal ideation, homicidal ideation, or acute psychosis requires emergent psychiatric consultation. ¹⁵ Some studies report the failure rate for diagnosing anxiety disorders as high as 50%. ²⁸ This can result in overuse of health care resources and increased morbidity and mortality rates for anxiety disorders and comorbid medical conditions. Listening to the patient and allowing expression of concern makes the patient feel safe.