Behavioural Disturbances Flashcards
Define acute behavioural disturbance…
Behaviour that puts a patient or others at immediate risk of serious harm
Aims of managing a patient with ABD?
- Reduce risk of harm
- Ascertain the most likely cause of ABD
- Transfer to definitive care
The _____ restrictive means possible should be used when managing a patient with ABD.
Least
The initial management strategy involving a patient with ABD is…
Verbal de-escalation
What are some common behaviours seen in ABD?
- Agitation
- Panic
- Yelling
- Disorganised behaviours
- Threatening self or others
- Aggressive or violent behaviours
There are several possible causes of ABD, and in some cases the cause can be ______________.
Multifactorial
What are the five general categories of causes of ABD?
- Substance related
- Organic
- Psychiatric
- Situational
- Behavioural
Examples of substances that can cause ABD?
- Alcohol
- Hallucinogens
- Psychostimulants
- Benzodiazepines
- Ketamine
- LSD
- Cannabis
- Other drugs
Examples of organic conditions that can cause ABD?
- Encephalitis
- Meningitis
- Infections
- Encephalopathy (especially in liver and/or renal failure)
- Seizures
- Hypoglycaemia
- Electrolyte disturbances
- Hypoxia
- Head injury
- Acute delirium
- Dementia
Examples of psychiatric conditions that can cause ABD?
- Schizophrenia
- Bipolar disorder
- Psychotic disorders
- Anxiety disorders
- Borderline and antisocial personality disorders
Examples of situational causes of ABD?
- Stress
- Pain
- Inability to communicate effectively
Examples of behavioural disorders that can cause ABD?
- Exacerbation of intellectual disability
- Impulse control disorders
- Autism
- Acquired brain injury
What is the tool used to guide decision making in regards to a patients anxiety and agitation?
Sedation assessment tool
In ABD what factors should alert the clinician that there is a possibility of an underlying medical condition?
- First presentation in a patient >45
- Abnormal VSS
- Focal neurological deficits
- Decreased awareness of surroundings
- Difficulty paying attention
- Absence of a clear trigger
Types of restraint?
- Physical
- Mechanical
- Pharmacological
Are QAS officers austhorised to apply mechanical restraints?
No. If mechanical restraints are applied by QPS or QCS the agency must be present with the patient at all times.
A physically restrained patient should be placed in which position?
Lateral with hands infront
Whilst monitoring a patients airway while physically restrained clinicians should ensure…
Airway is clear and no difficulty breathing
Why should patients not be placed in the prone position when physically restrained?
Risk of positional asphyxia
Why should patients not be positioned supine when physically restrained?
Risk of aspiration
When physically restraining a patient it is important to not?
- Restrict airway or circulation
- Apply direct pressure to head, neck, chest, back, abdomen, pelvis
- Block mouth or nose
- Flex head towards knees
- Inflict pain
- Obstruct mouth or ears (ability to communicate)
A physically restrained patient should be visually monitored for signs of physical and psychological stress, including…
- Distress
- Difficulty breathing
- Continual struggling
- Facial grimacing
How often should the physically restrained patient have VSS taken?
5 minutely
How often should a physically restrained patient have temperature taken?
15 minutely
Physical restraint should be applied for the ________ time possible.
Shortest
Categories of risk associated with physical restraint?
- Positional
- Pressure
- Exertional
- Patient’s health (co-morbidites and toxicology)
A patient must not be placed in the prone position for longer than?
2 minutes
If a patient is required to be positioned supine for a short period where should the clinician be situated?
At the patients head
Mechanism of pressure related risk to the chest, back and abdomen?
Weight impacts ability of diaphragm to move - leads to hypoventilation and respiratory failure
Mechanism of pressure related risk to the abdomen and pelvis?
Increases intra-abdominal pressure which decreased venous return, resulting in cardiovascular compromise
Sudden, unexpected death can occur in circumstances where a patient suffering from extreme agitation or ‘_______ ________’, is physically restrained.
Excited delirium
Which factors can contribute to sudden death in excited delirium patients?
- Forceful or prolonged struggle
- Exertion induced hyperthermia and acidosis
- Psychostimulant drug toxicity
- Underlying heart disease
- Positional asphyxia
- Restraint technique
- Obesity
Conducted energy weapons cause _____________ __________ through application of an electric current - which incapacitates a person and causes pain.
Neuromuscular disruption
Due to strong muscular contractions, CEWs can cause secondary injuries, including…
- Fractures
- Spinal injuries
- Head injuries
- Soft tissue injuries
- Hyperthermia
Can a taser cause cardiac arrest?
Yes, on rare occasions
CEW patients must be transported if?
- Probes in face, neck, groin
- Unable to remove probes due to resistance
- Non QPS CEW
- Known stimulant ingestion
- Significant cardiac history
- Known/suspected injuries
Does current literature support 12-lead ECG acquistion in patients with CEW exposures of less than 15 seconds if patient is asymptomatic, awake and alert.
No
How do you remove taser probes?
- Explain procedure
- Gloves, glasses
- Confirm probe not in face, neck, genitals
- Cut wire
- Stabilise skin non-dominant hand
- Pull probe/s until removed DO NOT twist
- Examine probe for completeness
- Probe into sharps
- Antimicrobial swab
- Consider wound dressing
The chance of infection with taser probe implantation is…
Extremely low
CEW patients can be left in the care of QPS if they…
- QPS CEW
- Probes removed and intact
- No requirement for medical/mental health assessment
- No evidence of stimulant ingestion
- No significant cardiac history
- No known or suspected injuries
Examples of factors that can contribute to suicidal ideation?
- Individual factors
- Job loss/unemployment
- Legal/criminal problems
- Financial problems
- Stressful life events
- Previous suicide attempts
- Serious illness
- Mental illness
- Substance misuse - Relationship factors
- Relationship break-up/loss
- Bullying
- Exposure to violence
- Adverse childhood events
- Family history of suicide - Social factors
- Barriers to accessing health care
- Suicide cluster
- Stigma associated with help seeking
- Access to lethal means
Clinical features in suicidal patients?
- Talking about death or suicide
- Seeking methods of self harm
- Hopelessness
- Changes in drug/alcohol use
- Uncontrolled emotions
- Reckless behaviour
- Changes in sleep pattern
- Feelings of isolation
- Social withdrawal
- Putting affairs in order
- Giving away possessions
- Anxiety or agitation
- Sudden mood changes
- Talking about being a burden
Protective factors for suicide risk?
- Ambivalence
- Future orientation
- Engagement in help seeking behaviours
- Coping and problem solving skills
- Support systems
- Availability of physical and mental health care
- Limiting access to lethal means
A suicide safety plan can include…
- EEA
- Transport to a place of safety
- Being in the care of a reliable and capable person who is willing to provide support and supervision
- Referral for further assessment and safety management
- Provision of support and helping services (Lifeline, local mental health service, Beyondblue)
If the QAS clinician believes a safety plan can manage risk in suicidal patients, the clinician must…
- Obtain advice from MHLS
- VIRCA
The MSE evaluates a patients thought processes at a particular ____.
Time
Can an MSE be used to diagnose a psychiatric condition?
No
Indication: MSE?
Behavioural disturbances
Components of the MSE?
- Appearance
- Behaviour
- Speech
- Mood
- Affect
- Thought form
- Thought content
- Perception
- Insight and judgement
The SAT is a useful tool for measuring _________ or ________ in patients with ABD.
Agitation, sedation
Indication: SAT?
All patients with ABD at regular intervals
Following sedation administration a SAT score should be assessed how often?
5 minutely
Is it mandatory to document regular SAT scores on all ABD patients?
Yes
EEA criteria?
- Behaviour indicates immediate risk of serious harm
- Risk as a result of a major disturbance in persons mental capcity
- Person requires urgent examination and care for the disturbance
Can a patient be transported to a watchhouse under an EEA?
No
Procedure for EEA?
- Confirm criteria met
- Inform patient
- Safely transport
- Make EEA once at destination
- Complete EEA prior to leaving destination
- Document any force used
Can the MHLS approve a patient being transported to a place of care under an EEA that is not a public health service?
Yes, under approval - also required approval from OpCen
Examples of ‘at immediate risk of serious harm?’
- Threatening suicide
- Self harm or threatening self harm
- Reckless behaviour
- Deterioration in mental state
- Illness symptomology (mania, psychosis)
- Aberrant behaviour
What must a patient be informed when placed under an EEA?
- They are being detained by QAS
- They will be transported by ambulance to hospital
- They will be detained at hospital for up to 6 hours
- Examined by a doctor at the hospital
What are the three medications indicated for sedation of an ABD patient within the QAS?
- Droperidol (ACP2 + CCP)
- Midazolam (ACP2 + CCP)
- Ketamine (CCP only)
Roles within an emergency sedation?
- Supervisor (senior clinician) - complete checklist and pre-sedation briefing
- Assistant - administer medication and continually reassess
Indication: Emergency Sedation?
- SAT 2 more AND
- Behaviour indicates imminent risk of serious harm to self or others AND
- Verbal de-escalation has failed
Contraindications for emergency sedation?
- Suffering or suspected to be suffering haemodynamic instability (hypotension, arrhythmias, shortness of breath, decreased peripheral perfusion, cyanosis)
- Compromised airway
- Contraindications for the sedation medication
