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78 T. M. Dunn and A. M. Nussbaum
Reverse possible causes.
Ö Have low index of suspicion for alcohol withdrawal.
Ö Treat infection, remove indwelling catheters, discontinue medi-
cines that are highly anticholinergic, etc.
Encourage being out of bed during the day and allow for as much
sleep as possible at night.
Ö During the day, room lights are on and shades are open.
Ö Television should be on, encourage family/friends to interact with
the patient.
Ö Intercom turned down at night.
Ö Minimize night-time interruptions, perhaps gathering vital signs
and administered medicine can be combined at the same time.
Ö Patient should be wearing their hearing aids and glasses during
the day.
{ Pharmacological treatment of delirium
Sedation may be required, particularly in a highly agitated patient.
Ideally, the level of sedation should be sufficient to ameliorate
agitation and other hyperactive symptoms, but only to the point where
the patient will rouse with stimulation.
Avoid benzodiazepines, particularly lorazepam (which is known to
precipitate delirium), unless treating alcohol withdrawal.
Avoid sleep aids that resemble benzodiazepines, especially zolpidem.
A safer treatment for insomnia is trazodone 50–200 mg prn insomnia.
Avoid polypharmacy.
Antipsychotics are commonly used to treat the behavioral distur-
bances associated with delirium.
Ö Haloperidol is an inexpensive dopamine antagonist available in
multiple formulations that has an excellent safety profile. It is
widely used for the treatment of delirium.
Ö Haloperidol is less anticholinergic activity than most antipsychotics.
Ö However, its use is associated with the prolongation of the QT
interval in a dose-dependent fashion.
Ö Consider starting haldol at 0.5mg PO/IM and increasing the dose
in half milligram increments until agitation is controlled.
— Take 50% of this loading dose and divide into q6 hour
increments.
Surgical Critical Care and Behavioral Health 79
— Taper down as patient improves.
— IV dosing of haloperidol should only occur with careful
cardiac monitoring.
Ö Generally, scheduled medication is more effective and better
tolerated than as needed dosing.
Patients with hypoactive delirium may still benefit from very low
doses (0.25 mg to 0.5 mg) of haloperidol.
• Substance Use Disorders
{ A person exhibiting signs (or reporting symptoms) of a mental illness may
be experiencing the effects of psychoactive substance use.
The variety of psychoactive substances that people use and misuse is
remarkable, so when seeking the cause of a patient’s distress, always
consider drugs of abuse, as well as prescription, over-the-counter,
sleeping aids, and herbal medicines.
Psychoactive substance use is common among persons admitted to
surgical services. In addition, surgical teams often prescribe psychoactive substances. People can experience mental distress during
substance use, intoxication, and withdrawal.
{ Consider these possibilities:
Substance Intoxication:
Ö People often underreport substance use. Urine and serum lab
tests include common substances, but do not include many
psychoactive substances like synthetic cannabinoids and club
drugs, so a “negative utox” does not rule out intoxication.
Ö Many states have online registries to track controlled substance
administration, to help confirm or deny suspicions about a
patient’s substance use.
Ö To prevent intoxication, we recommend judicious prescription of
psychoactive substances only when necessary.
Substance Withdrawal:
Ö Most psychoactive substances have a characteristic withdrawal
syndrome.
Ö Treatment protocols exist to treat most withdrawal syndromes,
usually focusing on symptomatic treatment.
80 T. M. Dunn and A. M. Nussbaum
— We caution against using these protocols automatically as they
often include substances that can mask dangerous clinical
signs.
— For example, in many hospitals it is common to place persons
with opiate use disorders on a clinical opiate withdrawal scale
(COWS) protocol.
— The COWS protocol includes clonidine, which reduces auto-
nomic hyperactivity, but does not prevent withdrawal seizures.
— Instead, we advise that treatment should be focused on those
substances for which withdrawal can be lethal.
Ö Alcohol withdrawal
— Early treatment can prevent complicated withdrawal. Multiple
withdrawal protocols (CIWA, SEWS, etc.) are available and
many hospitals will have a preferred protocol.
— While we generally recommend judicious use of benzodiaz-
epines in the surgical critical care setting to reduce the risk of
delirium, benzodiazepines (especially diazepam or lorazepam)
are the cornerstone of treatment for alcohol treatment.
Ö Benzodiazepine withdrawal
— No standard protocol exists for treating benzodiazepine
withdrawal, which is typically prolonged because of the comparatively long half-life of many benzodiazepines, especially
clonazepam.
— The first step is to determine the daily dose of benzodiaz-
epines, the duration of benzodiazepine use, and the presence or
absence of physiological dependence.
— For a person who is physiologically dependent on benzodiaz-
epine, it is preferable to decrease daily benzodiazepine dose
gradually, by 20% per week, to avoid withdrawal seizures.
— In an acute setting, a loading dose of a long-acting benzodiaz-
epine like diazepam (initial doses are typically 30–50 mg) can
be given and then transition to schedule doses.
— Avoid the use of as needed benzodiazepines.
— Avoid the use of the short-acting benzodiazepine alprazolam,
which is frequently abused and diverted.
Ö Barbiturate withdrawal:
— While barbiturate use has markedly decreased over the past
two decades, barbiturate withdrawal can be lethal.
Surgical Critical Care and Behavioral Health 81
— The treatment is essentially the same as benzodiazepine
withdrawal.
9 However, if a patient has epilepsy (as opposed to a history
of withdrawal seizures), consulting a neurologist is recommended.
{ Substance Use
Substance use and misuse complicates surgical treatment and recovery.
Screening for substance use, encouraging cessation, and referring
patients to substance use treatment is critical.
Ö Many hospitals will have substance abuse counselors who can
speak to patients as they near discharge.
Ö At discharge, careful medication reconciliation to minimize the
availability of drugs of abuse is advised.
{ The Methadone Patient
Methadone maintenance programs are subsidized treatment programs
for those with Opioid Use Disorder.
There are strict laws about dispensing methadone as part of an addic-
tion treatment regimen.
It is prudent to continue to treat these patients who will withdraw
while admitted if their regimen is not followed.
• Self-harm
{ In the U.S., more people die each year from suicide than from motor
vehicle collisions.
Surgeons frequently treat people who have either survived suicide
attempts or have engaged in self-injurious behavior without intent to die.
{ More than half of all suicide attempts involve intentional ingestions,
which have low rates of mortality.
Attempts using firearms have the highest rates of morbidity and
mortality, followed by hanging and jumping from heights.
While cutting is very common, its overall mortality rate is about 1%.
{ The demographic most highly associated with completed suicide is older
white men, living alone, unemployed, abusing substances, with a chronic
medical condition, who are not participating in a faith community. Further,
90% of people who complete suicide have a diagnosed mental disorder.
Depression, hopelessness, and despondence are correlated with
suicide.
82 T. M. Dunn and A. M. Nussbaum
Psychotic individuals may also engage in self-harm because of delusions.
Men tend to use lethal means of harming themselves and have higher
rates of completed suicide.
Suicide attempts often follow a significant life stressor, such as job
loss or a relationship ending.
Involving a firearm in a suicide attempt has a fatality rate above 80%.
The military has noticed very high rates of suicide among veterans of
the Afghanistan and Iraq wars, particularly those serving in the army.
{ Surgeons should be wary of individuals from high-risk groups who have
suspicious injuries, such as patients:
With any self-inflicted gunshot wound, despite claims that it was
accidental.
Involved in single vehicle motor vehicle collisions.
With unexplained falls from heights.
{ Despite severe self-inflicted injuries and a patient who may intubated,
involving a consulting psychiatrist or psychologist early in the patient’s
course is prudent.
Collateral information identifying the particular circumstances of the
injury can be ascertained.
Disposition of mental health holds are time sensitive.
Continuity of care is increased.
• Involuntary detention of the mentally ill who are dangerous.
{ In the North America, it is generally believed that thoughts of suicide or
suicidal behavior are pathological.
It is also widely accepted that those who are mentally ill and
potentially dangerous lose their capacity to refuse evaluation and
treatment.
Some cultures, however, may accept ritualized suicide.
{ All states have mechanisms to detain individuals who are believed to be
mentally ill and dangerous.
Some states allow detaining individuals who may be dangerous to
property (such as fire setting).
Substance use disorders may also meet criteria.
Many states also allow the involuntary treatment of individuals whose
mental illness is so severe, it makes them gravely disabled and unable
to take care of themselves.
Surgical Critical Care and Behavioral Health 83
{ While the specifics change from state to state, most jurisdictions allow for
an emergency detention of a mentally ill person who is believed to be a
danger to self or others and is refusing voluntary treatment.
Emergency detention lasts a short period of time and permits evalu-
ation of the patient.
The evaluation is time limited to serve as a check against unlawful
detention.
Ö In many states, this time limit is 72 hours; however this period of
time ranges from 24 hours (Texas) to 15 days (Connecticut).
During the emergency detention, the patient is evaluated and a deter-
mination is made if longer involuntary detention is required.
Ö If longer detention is required, then judicial review is invoked and
evidence presented in a court of law regarding whether the patient
should be committed.
{ Involuntary treatment of a person with mental illness also varies widely
from state to state.
Even involuntary detained mentally ill persons retain the right to
refuse psychotropic medication unless they are a danger to self or others.
Many states allow the pharmacological treatment of treatment of indi-
viduals over their objections, by force if necessary, but only after a
court order.
Some jurisdictions allow the involuntary treatment of psychiatric
patients accused of a crime to restore their competency to stand trial.
Other states have very strict regulations about forcibly treating the
mentally ill to a very narrow set of circumstances and only under
extraordinary conditions.
Ö This includes physical restraint.
{ Typically, such mental health holds are unnecessary with patients who are
voluntarily seeking treatment.
Further, involuntary detention is not necessary in instances where the
patient is incapable of making informed medical decisions.
Ö The intubated and sedated patient does not need to be on a mental
health hold.
Ö Children typically do not need to be held involuntarily.
Ö The patient impaired by intoxication or substance withdrawal,
shock, or delirium.
84 T. M. Dunn and A. M. Nussbaum
{ Recall that many states forbid the involuntary medication of patients
being detained unless approved by a court.
The delirious patient who is so confused that he cannot make medical
decisions technically cannot receive an antipsychotic like haloperidol
(in some states) without a court order.
Ö Despite this being the treatment of choice and done in the per-
ceived best interests of the patient.
{ Acute surgical patients whose injuries are due to self-harm may often be
best managed by considering them as having impaired medical decisionmaking capacity.
This allows the surgeon to make a life- or limb-saving intervention
despite the patient objecting to the procedure.
Ö It is presumed that if the patient were not impaired by their sui-
cidal wishes, he or she would consent to the treatment.
It permits using standard patient restraint protocols in surgical set-
tings, such as those designed to prevent accidental extubations, or
removing indwelling catheters.
Initiating a mental health hold starts a clock on how long the indi-
vidual can be detained over his or her objections.
Ö It does no good to have the clock running when the patient is intu-
bated.
Protocols and state laws about the treatment of a patient lacking
medical decision-making capacity permits keeping patients safe by
not permitting AMA discharge.
Ö Be certain to include proxy decision-makers when treating patients
who lack decision-making capacity to refuse treatment.
• Mental Illness and the Surgery Patient
{ The vast majority of persons with mental illness suffering a co-occurring
surgical condition will require only standard surgical care.
It is prudent to continue home psychiatric medications, unless medi-
cally contraindicated.
{ Patients with preexisting depression or anxiety may experience relapses
with the added stress of surgical condition.
Changes in psychiatric medication regimen should be coordinated
with a patient’s outpatient mental health practitioner.
Surgical Critical Care and Behavioral Health 85
• The Traumatized Surgical Patient
{ Psychological trauma often co-occurs with physical trauma.
While it is widely recognized that individuals injured in violent
confrontations (such as combat or violent crime) may have an untoward psychological reaction to their injury, those with more mundane
mechanisms of injury (such as a motor vehicle collision), may also
experience problems.
Having suffered physical trauma sufficient to require surgery pre-
disposes patients to suffering from a trauma- or stressor-related
disorder.
Severe illness and surgery may be sufficiently traumatizing to
precipitate a trauma-related psychiatric condition.
{ It should be noted that there are a range of presentations that may occur
following a traumatic event that are not, necessarily, pathological.
It is not unusual for injured individuals to report nightmares, restless-
ness, fear, and depressed mood (among other symptoms).
Typically, however, these symptoms are short-lived and not severely
impairing.
Severely impairing symptoms are those that
Ö Are the source of considerable personal distress.
Ö Persist beyond a few days.
Ö Impair patients’ ability to participate in their treatment.
Ö Cause impairment in the patient’s ability to interact with others.
Ö Present as being grossly out of proportion with extent of injury
suffered.
{ When patient’s psychological reaction becomes severely impairing,
it may meet the criteria for either acute stress disorder (ASD) or
posttraumatic stress disorder (PTSD).
Both ASD and PTSD are psychiatric conditions which follow a trau-
matic event where an individual is exposed to threat of death, severe
injury, or sexual violation. Their major difference is when symptoms
appear.
Ö The onset of ASD is from three days after the traumatic event to
one month.
Ö Symptoms that continue past one month, or impairment that does
not start until a month after the event is PTSD.
86 T. M. Dunn and A. M. Nussbaum
While ASD and PTSD have separate diagnostic criteria beyond time
of onset, generally, both share the following symptoms:
Ö Symptoms of intrusion, such as nightmares, flashbacks, intruding
thoughts about the event.
Ö Negative mood, such as depression, irritability, etc.
Ö Dissociative symptoms, such as having trouble remembering
important features of the traumatic event.
Ö Avoidance of things that remind the individual of the trauma.
Ö Hyperarousal, such as difficulty sleeping, restlessness, exagger-
ated startle response, angry outbursts, problems with attention and
concentration.
{ Treatment of ASD/PTSD in the surgical critical care setting.
As many surgical patients report sub-clinical symptoms of ASD/
PTSD, a prudent surgeon can warn his or her patients that these
distressing symptoms are common responses.
The treatment literature for ASD/PTSD is most germane to the outpa-
tient behavioral health setting.
Treatment of ASD/PTSD in the surgical critical care setting may
be best directed at short-term management of the most severe
symptoms.
Ö Nightmares, hyperarousal, and sleep disturbance may subside with
prazosin.
Ö Extreme anxiety may respond to a short-course of a sedating
medicine, such as hydroxyzine 50 mg po q6 prn anxiety, trazodone
50–200 mg po q6 prn insomnia, which can be continued at
discharge if necessary.
Ö If these prove insufficient, judicious use of a benzodiazepine like
lorazepam or clonazepam, or even a sedating antipsychotic like
haloperidol, quetiapine, or olanzapine may be indicated. These
medications should usually be discontinued at discharge.
Ö Patients who require intervention during their acute surgical
care for severe stress reactions should be referred for outpatient
treatment of ASD/PTSD.
• Psychiatric Conditions Presenting with a Surgical Complaint
{ DSM-5 renames somatoform disorders “Somatic Symptom and Related
Disorders.”
Hypochondriasis has been replaced by “Somatic Symptom Disorder”
for a person with significant somatic symptoms and significant health
Surgical Critical Care and Behavioral Health 87
anxiety. The diagnosis of Pain Disorder is now a subtype of Somatic
Symptom Disorder.
For a person with minimal somatic symptoms, but significant health
anxiety, DSM-5 replaces hypochondriasis with “ Illness Anxiety
Disorder.”
{ Factitious Disorder
Individuals with Factitious Disorder are known to deceptively induce
illness or injury to themselves for reasons other than secondary gain
(e.g., financial settlement, narcotic pain relievers, coping with homelessness).
Such individuals are clearly making themselves ill or creating a con-
dition requiring surgical intervention, but hiding this fact from care
providers.
Ö Precisely why individuals engage in this behavior is debated in the
literature.
Ö Generally, if a satisfying explanation for the behavior can be
identified, then the condition is not likely Factitious Disorder.
Ö Less likely are patients with this condition who feign particular
symptoms.
While there are varying presentations of Factious Disorder, these
individuals have some unifying features.
Ö A tendency to go from hospital to hospital with dramatic
complaints, telling fantastic stories.
— Likely to have lengthy medical records.
— Often reluctant to allow providers to request medical records.
— May have a “gridiron gut.”
Ö They often have an unusual understanding of medical terminology
and jargon for a layperson.
— Although, often these individuals may have worked in
healthcare at an entry level position (such as a medical
assistant or technician).
Ö Women in their 20s and 30s are over-represented.
Ö Often present as hostile, controlling, and angry during admission.
Ö May have a history of substance use disorder.
{ Often, those with Factitious Disorder:
Ö Are eager for a medical test or procedure that would make other
people worried or uncomfortable.