Question 2. In the patient with new-onset psychosis without focal neurologic deficit, should brain imaging be obtained acutely?

Patient Management Recommendations
Level A: None specified.
Level B: None specified.
Level C: Use individual assessment of risk factors to guide brain imaging in the emergency department for patients with new-onset psychosis without focal neurologic deficit (consensus recommendation).

There were no Class I, II, or III studies to answer this question. In the Class X studies that did categorize imaging abnormalities, the percentage of imaging findings described as being clinically relevant, influencing clinical management, or altering diagnosis ranged from 0 percent to approximately 5 percent.

While the number of mental health–related visits to emergency departments has increased steadily, the number of inpatient psychiatric beds has decreased.

Question 3. In adult patients presenting to the emergency department with suicidal ideation, can risk-assessment tools in the emergency department identify those who are safe for discharge?

Patient Management Recommendations
Level A: None specified.
Level B: None specified.
Level C: In patients presenting to the emergency department with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account.

Class III studies were identified that investigated whether risk assessment can identify patients who are at risk for future self-harm. The designs of these studies were problematic, and no tool has been demonstrated to accurately predict the risk of suicide among patients in the emergency department.

Question 4. In the adult patient presenting to the emergency department with acute agitation, can ketamine be used safely and effectively?

Patient Management Recommendations
Level A: None specified.
Level B: None specified.
Level C: Ketamine is an option for immediate sedation of the severely agitated patient who may be violent or aggressive (consensus recommendation).

Management of acutely agitated patients in the emergency department remains a critical issue. Most of these patients can be sedated safely with antipsychotics and/or benzodiazepines. However, there remains a subset of extremely agitated patients for whom this approach will not be effective. These patients have a significant effect on the emergency department staff in terms of time and dedicated resources required to maintain a safe environment for patients and others in the emergency department. Although there is a lack of Class I, II, or III studies establishing the safety and efficacy of ketamine to control acute agitation in the emergency department, the skills set of emergency physicians and their familiarity with the use of ketamine make it a reasonable choice when immediate control of the acutely agitated patient is required for patient and/or staff safety.