Emergent Management of Anorexia Nervosa Treatment & Management

  • Author: Ron D Waldrop, MD, MS, FAAP, FACEP, FACPE; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Jun 17, 2011
 

Approach Considerations

Metabolic abnormalities in patients with anorexia nervosa should be corrected as needed, with oral or parenteral treatment depending on the patient's mental status and decision to cooperate. Hospital admission may be indicated for patients who are extremely ill, have cardiac dysrhythmias, or have severe metabolic abnormalities. Most patients will be admitted to medical facilities for re-feeding, referred to psychiatric facilities and counseling if medically stable, or be managed on an outpatient basis.

It is not necessary to begin parenteral nutrition in the emergency department; the focus should be on stabilization of acute abnormalities while an inpatient team including nutrition specialists can determine a re-feeding schedule. The process of re-feeding must be undertaken slowly, with modest increases in metabolic demands to avoid heart failure and a "re-feeding syndrome" that includes life-threatening dysrhythmias and hypophosphatemia. Ideal weight gain should occur at a rate of 1-2 lbs per week.

Inpatient treatment in a medical facility should always include psychiatric consultation for ongoing treatment of the underlying anorexia nervosa while addressing the acute medical complications of malnutrition.

Acute pharmacologic treatment of anorexia nervosa is rarely required, and cases of extreme altered mental status or psychosis should prompt a search for underlying profound metabolic disorders. The psychopharmacology of anorexia nervosa should be determined in consultation with a psychiatrist.

As with all psychiatric and behavioral emergencies, care must be taken to prove and document competency upon discharge. Many patients with anorexia nervosa may have additional psychopathology, which leaves them incapacitated during an anorexic crisis. If doubt remains, the patient must be admitted for more thorough psychiatric and physiologic monitoring or discharged in the care of a competent caretaker.

Transfer to an inpatient psychiatric facility may be the disposition for patients who are medically safe for discharge but who require aggressive inpatient psychiatric treatment of their disorder.

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Indications for Hospital Admission

Life-threatening or potentially lethal abnormalities require admission. Indications for hospitalization include the following:

  • Bradycardia or other cardiac dysrhythmias
  • Severe electrolyte abnormalities, especially of potassium, sodium, and phosphorus levels
  • Altered mental status or suicidality
  • Extremely low body weight
  • Failure of outpatient treatment
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Consultations

Most cases of anorexia nervosa encountered in the emergency department will be appropriate for outpatient management if close, planned follow-up is arranged prior to discharge. Consultation with the pediatrician or primary care physician is necessary to arrange follow-up. Urgency of follow-up depends on the patient's condition and how soon the laboratory study results will need to be reevaluated.

Psychiatric consultation in the emergency department should be considered for patients expressing suicidality, psychosis, or severely disordered thinking. Outpatient psychiatric follow-up is necessary and may be arranged either from the ED or by the primary care provider.

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Long-Term Monitoring

Close follow-up with the primary care physician is very important.

Patients with anorexia nervosa should have their weight and electrolytes checked within a week of their emergency department visit.

Outpatient psychiatric treatment should be arranged as soon as possible from either the emergency department or a primary care referral.

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Contributor Information and Disclosures
Author

Ron D Waldrop, MD, MS, FAAP, FACEP, FACPE  Emergency Physician, Commonwealth Emergency Physicians; Director of Pediatric Quality Care Management, Inova Loudoun Hospital; Adjunct Clinical Professor, Georgetown University School of Medicine

Ron D Waldrop, MD, MS, FAAP, FACEP, FACPE is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Tracy A Cushing, MD, MPH, FACEP, FAWM  Assistant Professor, Department of Emergency Medicine, University of Colorado School of Medicine; Attending Physician, Denver Health Medical Center

Tracy A Cushing, MD, MPH, FACEP, FAWM is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert Harwood, MD, MPH, FACEP, FAAEM  Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine

Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of Siobhan O'Herron, MD,to the development and writing of the source article.

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