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Y5 Emergency Medicine > 13 - Acute Psychiatry and Alcohol Misuse > Flashcards

13 - Acute Psychiatry and Alcohol Misuse Flashcards

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1
Q

What are two screening tools for harmful alcohol use?

A

- CAGE
- AUDIT

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2
Q

How do you screen for alcohol misuse using CAGE and how do you interpret the results?

A

CAGE questions should not be preceded by any questions about alcohol intake

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3
Q

How do yu screen for alcohol misuse using AUDIT-C and how do you interpret the results?

A
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4
Q

What questions can you ask in an alcohol history?

A

Origin of the drinking problem
Ask the patient when they first noticed an increase in their alcohol intake and try to identify any factors that played a role in this

Current drinking pattern
“How often do you drink alcohol?”
“Do you drink every day?”
“Do you drink at a particular time of day?”
“How much do you drink on an average day?”
“Is there anything that makes you drink more or less in a day?”
“How much do you spend on alcohol each week?”

Drinking behaviours
- “Where do you drink?”
- “Who do you drink with?”

Previous attempts at abstinence
- “Have you ever tried to stop before?”
- “What happened when you tried?”
- “Did you have any support?”
- “Why do you think it was unsuccessful?”

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5
Q

What are the two different types of dependences on alcohol and how can you screen for them?

A

Biological dependence
- “If you stop drinking, do you…get the shakes/sweat a lot/feel sick/notice any physical changes?”
- “Do you have to drink more than you used to, to get the same effects?”

Psychological dependence
“Do you feel a compulsion/need to drink?”
“How important is drinking to you?”
“If you stop drinking, do you notice that you…feel down/angry/anxious?”

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6
Q

If you suspect someone is misusing alcohol what can you ask them about their day to day life?

A
  • “Has alcohol impacted any of your personal relationships?”
  • “Has alcohol had any impact on your job or ability to work?”
  • “Do you currently drive?”
  • “Have you ever driven whilst under the influence of alcohol?”
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7
Q

What are some alcohol related medical conditions?

A
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8
Q

What are another two dependencies that can co-exist with alcohol dependence that you should ask about?

A
  • Smoking
  • Gambling
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9
Q

What are the stages/complications of alcohol withdrawal once dependent?

A

6-12 hours: symptoms start e.g tremor, sweating, tachycardia, anxiety

36 hours: peak incidence of seizures

48-72 hours: peak incidence of delirium tremens. Coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

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10
Q

What medication should you give if you suspect someoen is undergoing alcohol withdrawal?

A

- Long acting benzodiazepine(e.g chlordiazepoxide) as a reducing dose regime

-Parenteral thiamine followed by oral thiamine to prevent Wernicke’s encephalopathy

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11
Q

If someone develops delirium tremens this is an emergency. How do you treat it? (characterised by agitation, confusion, paranoia, and visual and auditory hallucinations)

A

Oral Lorazepam

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12
Q

What is GMAWS?

A

Glasgow Modified Alcohol Withdrawal Scale (GMAWS)
- Tremor
- Sweating
- Hallucinations
- Orientation
- Agitation

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13
Q

What medications can be given to prevent relapse of alcohol dependence?

A
  • Acamprosate
  • Naltrexone
  • Disulfiram

Check if need enzyme supplements due to pancreatic exocrine insufficiency (e.g steatorrhoea)

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14
Q

What services can you refer to for alcohol misuse?

A
  • Turning Point
  • Alcoholics anonymous
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15
Q

What are the key steps for successful alcohol withdrawal?

A

- Benzo cover
- Psychological intervention
- Relapse prevention
- Support/support groups

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16
Q

What criteria needs to be met for assisted alcohol withdrawal?

A

Drink over 15 units of alcohol per day, and/or who score 20 or more on the AUDIT

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17
Q

What are the common types of posioning/overdose?

A
  • Paracetamol
  • Salicyclate
  • Opioids
  • Benzos
  • TCAs
  • Lithium
  • Warfarin
  • Heparin
  • Methanol
  • Organophosphates
  • Digoxin
  • Iron
  • Lead
  • Cyanide
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18
Q

How do you manage any overdoses/poisoning initially?

A
  • Brief history of what taken, how much and when
  • A to E
  • Consult TOXBASE
  • Consider gastric lavage if <1 hour
  • Take mental health history and refer
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19
Q

What investigations should you consider in your A to E when someone has an overdose/poisoning?

A

- ABG
**- Bloods: **FBC, U+Es, LFTs, salicyclate and paracetamol levels, glucose, PT/APTT
- Urine toxicology
**- ECG ** for arrhythmias or long QT

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20
Q

What are two important observations to monitor in an overdose?

A
  • GCS
  • RR
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21
Q

What is the treatment for the following overdoses:

A
22
Q

What is the treatment for the following overdoses?

A
23
Q

What is the treatment for lithium toxicity?

A

Hydration

If severe then haemodialysis

24
Q

After someone has taken an overdose and it has been managed, what questions do you need to ask them about their mental health?

A

DO A FULL MENTAL HEALTH HISTORY

- How they feel about it all now?
- Any trigger?
- Extent of planning/prep
- Circumstances of seeking help
- Any previous suicide attempts
- PMHx e.g depression
- DHx
- SHx (find out who supports them)

25
Q

If someone is unconscious or refusing to tell you what they have taken for an overdose, what are some symptoms you can enquire about to help you figure out what they have taken?

A
  • Vomiting?
  • Tinnitus?
  • Abdo pain?
  • Dizziness?
26
Q

What are some signs and symptoms of the following overdoses:
- Salicyclates
- TCAs
- Digoxin
- Opioids
- Benzos/alcohol
- Ectasy/cocaine/amphetamines

A
27
Q

What investigations should you do if you suspect and overdose of the following substances
- Salicyclates
- TCAs
- Digoxin
- Opioids
- Benzos/alcohol
- Ectasy/cocaine/amphetamines

A
28
Q

In a paracetamol overdose what is considered a significant ingestion amount?

A

> 75mg/kg/hr

If someone has ingested >150mg/kg less than an hour ago start NAC immediately

29
Q

What are the signs of paracetamol OD?

A

Initially no symptoms then after 24h may have N+V and RUQ pain

30
Q

What is a scoring system you can use to assess risk after a suicide attempt?

A

DO NOT USE THIS SCORING SYSTEM TO MAKE DECISIONS, IT IS OUTDATED

SAD PERSONS score

<6: may be safe to discharge

6-8: probably needs psych assessment

> 8: likely admission and urgent psych assessment

31
Q

GO AND REDO DECK 6 PSYCHIATRY

A

IMPORTANT TO GO OVER SUICIDE AND DELIBERATE SELF HARM HISTORY

32
Q

What are some services you can refer people to with deliberate self harm?

A
  • Mind
  • Harmless
  • Rethink
  • Samaritans

Refer to CAHMS if child

33
Q

What is the most important assessment to start when an acute psychiatry case comes in?

A

Psychosocial by mental health professional

Don’t wait until medical treatment is done to start this

34
Q

As a non mental health professional in ED what questions do you need to answer when deliberate self harm occurs?

A
35
Q

What psychological intervention can you refer people to who deliberately self harm?

A

Structured CBT or DBT if child

36
Q

When should you use IM Lorazepam instead of IM Haloperidol for rapid tranquilisation?

A

If there is cardiovascular disease, long QT or no ECG available

Or if have Parkinson’s

37
Q

What is important to do after physical aggression in the acute psychiatric setting?

A

Post-incident debrief within 72 hours with all members of the team

38
Q

If a patient becomes aggressive or violent in ED with a mental health problem what should you do?

A
  • Deescalation techniques
  • Treat as psychiatric emergency and refer the service user to mental health services urgently for a psychiatric assessment within 1 hour
39
Q

Manual restraint should only be used in extreme circumstances if other methods have not worked. What should be done when manually restraining?

A
  • Avoid taking the service user to the floor, if so use supine position
  • Do not use manual restraint in a way that interferes with airway, breathing or circulation
  • Do not use manual restraint in a way that interferes with the patient’s ability to communicate, for example by obstructing the eyes, ears or mouth.
  • Do not routinely use manual restraint for more than 10 minutes
  • Consider rapid tranquillisation or seclusion as alternatives to prolonged manual restraint (longer than 10 minutes).
  • Ensure that the level of force applied during manual restraint is justifiable, appropriate, reasonable, proportionate to the situation and applied for the shortest time possible.
40
Q

What is the target time for a mental health review from liason psychiatry in the ED?

A

1 HOUR

41
Q

Where should liason psychiatry assess mental health patients in ED?

A

Designated interview room with at least one other staff member and an emergency buzzer

42
Q

How do you do a mini mental state score?

A

Out of 30

A score of 25 or higher is classed as normal. If the score is below 24, the result is usually considered to be abnormal, indicating possible cognitive impairment

43
Q

What are some psychiatric causes of acute confusional state?

A
44
Q

GO AND DO DECK 1 OF PSYCHIATRY

A

NEED TO DO MENTAL STATE EXAMINATION

45
Q

What mental health act can you use in ED?

A
  • Section 135/136 imposed by the police (135 in home, 136 in public place)
    - Section 2 for assessment if 2 doctors and one is section 12 approved
  • Common lawif they are trying to leave and may harm someone or themselvs

Cannot use Section 5 as not an inpatient when in A and E

46
Q

Can you treat someone in A and E for their mental health condition if they lack capacity?

A

No MCA doesn’t cover this need to use the mental health act

47
Q

REDO DECK 15 OF PSYCHIATRY

A

IMPORTANT

48
Q

REDO DECK 10 OF PSYCHIATRY

A

NEED TO KNOW THE MENTAL HEALTH ACT INSIDE OUT ESPECIALLY TIMES FOR EACH SECTION AND USE IN ED

49
Q

If a patient is agitated what key principles should you consider when managing them?

A
  • Disengage
  • Offer alternatives to their demands e.g we have blue or green cups not red which would you like
  • Stay near to the door
  • If restraining need 6 people
50
Q

Why do yoiu need 6 people for restraint?

A
  • 1 for airway and to prevent head and neck
  • 4 for limbs
  • 1 to be team leader and do observations of patient
51
Q

What is the maximum time you are allowed to restrain someone for?

A

10 minutes

Avoid taking them to the floor
Once finished do a debrief and ensure all notes inc timing and who was involved in the patient’s notes

Y5 Emergency Medicine (14 decks)

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