Treatment

When it comes to ED treatment of patients with eating disorders, besides addressing immediate life-threatening complications, there should be no specific treatment initiated. It may be tempting to administer crystalloid boluses to patients with eating disorders who appear to be dehydrated in the ED; however, this should be avoided because a common cardiac complication is heart failure. It also might be tempting to administer dextrose in the ED; however, this should also be avoided as it increases the risk for refeeding syndrome.

The American Academy of Pediatrics admission criteria for adolescents with an eating disorder include: less than 75 percent median BMI for age and sex, dehydration, electrolyte disturbance (hypokalemia, hyponatremia, hypophosphatemia), ECG abnormalities (severe bradycardia or prolonged QTc), heart rate less than 50 beats per minute daytime or less than 45 beats per minute at night, blood pressure less than 90/45, temperature less than 96, orthostatic pulse increase greater than 20 beats per minute or decrease in blood pressure greater than 20 systolic or greater than 10 diastolic, arrested growth and development, failure of outpatient treatment, acute food refusal, uncontrollable binge eating and purging, acute medical complications of malnutrition (syncope, seizures, heart failure, pancreatitis, etc.), and comorbid condition that prohibits or limits appropriate outpatient treatment (severe depression, suicidal ideation, obsessive compulsive disorder, Type 1 diabetes).¹⁸

A common pitfall is reassuring a patient with an eating disorder that they have a normal physical exam and investigations. Both physical exam and lab findings may be normal in patients with severe eating disorders. This false reassurance reinforces the common perception by the patient that they do not have an eating disorder and is counterproductive to initiation and maintenance of treatment. Do not minimize the illness.

Have a low threshold to consult pediatrics, internal medicine, or psychiatry, and/or refer to the local outpatient eating disorder program for a multidisciplinary assessment. Timely follow-up in a clinic with experience managing patients with eating disorders is essential. Generally, primary care physicians are not equipped to manage eating disorders alone and should not be the sole follow-up care provided.

Next time you are faced with a young person who presents to the ED with vague symptoms, it is imperative to consider eating disorders. Ask a few simple screening questions. Obtain repeat resting vital signs including orthostatic vitals. Perform a focused physical exam looking for clues of eating disorders. Order appropriate investigations, and have a low threshold for consultation or timely referral to a clinic familiar with eating disorders management. With these principles in mind you are more likely to pick up these often elusive diagnoses, get them on the road to early initiation of treatment, prevent chronic relapsing disease, and, potentially, save another life!