The patient with post-traumatic stress disorder in the emergency department

Abstract

As emergency physicians (EPs), we work in the midst of constantly evolving human drama. We also bear witness to intense events that our patients may experience as profound psychological trauma. In contrast to our extensive experience in handling acute medical crises, for most EPs, it is relatively unusual to encounter patients presenting solely for treatment of psychiatric complications from traumatizing events. Rather, it is more common for these patients to present with various somatic complaints that cannot be explained by a unifying diagnosis [1]. These patients often have residual symptoms from remote trauma and may lack awareness that their acute symptoms are due to an underlying psychiatric etiology. Although patients with mild or moderate symptoms are much more likely to visit their primary care physician, EPs play an important role in diagnosing cases among those without primary care or who manifest symptoms that mimic life-threatening pathologies such as acute coronary syndrome and stroke [2]. This chapter will highlight the two specific psychiatric manifestations of trauma as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), acute stress disorder (ASD) and its counterpart post-traumatic stress disorder (PTSD) [3]. In addition, it will discuss management strategies for patients with ASD/PTSD in the emergency department (ED) and how the EP can effectively identify the various presentations of PTSD, even when the symptoms are subthreshold for a formal diagnosis [4]. For a comprehensive discussion of normal and pathologic reactions to acute trauma and techniques to manage these patients in crisis, see Chapter 32, Trauma and loss in the emergency setting, in this text.