Emergency department psychiatry Flashcards
How would you assess suicide risk in a patient presenting following an attempt?
Split into into before, during and after Before: -Events leading up to suicide event -depressive symptoms -Planning - how long between thinking of overdose and doing it -suicide note/tell anyone -precautions During: -How exactly did you do it -When and where -Who discovered you -Any alcohol/drug intoxication After: -Feelings now -angry/regretful -Future feelings: if you go home now what would happen? -If changed their mind ask what has changed
In patients who have attempted suicide what are the 4 stages in trying to help survivors?
- Agree a contract of offering help, discuss confidentiality and help set up support network for tackling problems
- treat any comorbid conditions e.g. depression, anxiety, substance misuse
- Problem solving therapy - helps point out to patients how they solved past problems
- Follow up with preventative stretagies e.g. promote access to samaritans, limit access to lethal means, social support if needed
If a patinet presents with depression and no previous suicide attempts then what questions can be asked to elicit risk?
Any plans?
What where when?
Are means available?
Other attempts?
Seriousness?
Preperations e.g. writing will, giving things away?
Ask social history to establish risk factors
What are the symptoms of depression to ask about?
Anhedonia (inability to enjoy) Low mood Fatigue Insomnia Poor appetite Psychomotor retardation Feelings of worthlessness Reduced concentration
What are the risk factors for suicide?
SAD Persons Sex - mlae Age - young or old Depression Previous suicide attempt Excessive alcohol use Rational thinking loss Seperated/widowed Organised/serious suicide attempt No social support Stated future intent
What are the risk factors for deliberate self harm?
Witnessing DSH e.g. family member
Biological - reduced endorphin response to emotional arousal
Developmental - physical, sexual or emotional abuse
Peer relations - conflict
Psychological - identity problems
Antisocial behaviour
How do you manage a patient with deliberate self harm?
Need to remember to treat the medical problems resultling from the self harm first
Need sufficient analgesia for suturing or other painful procedures etc.
Need specialist assessment for mental health however this must be balanced with risk of delay
If assessing:
-Initial risk management - immediate risk of suicide, need for admission
-Ongoing risks of subsequent DSH
-Relevant psychiatric, medical and social issues
How do you deal with a patient trying to leave before assessment has been completed?
Discuss with the patient why they want to leave
Consider if they have a serious medical illness or diminished capacity and if they need to be detained
What is the management of dealing with intoxicated patients?
Most patients need to wait until they have sobered up before being assessed however it is important their medical needs are not ignored
What are the symptoms of neuroleptic malignant syndrome?
Fever
Muscle rigidity
Autonomic instability
Markedly raised serum creatine kinase
What is the management of neuroleptic malignant syndrome?
Stop the causative factor, treat rhabdomyolysis, use supportive measures and admit
How do you rapidly tranqullize a difficult patient?
Offer oral medication first:
-If on antipsychotics then lorazepam 1-2mg
-If not on antipsychotics then quetiapine or risperidone
-Avoid using more than one antipsychotic as this causes QT prolongation
If the patient is placing themselves at considerable risk consider IM:
-Lorazepam - have flumazenil to hand for respiratory depression
-Promethazine is good if patient is benzodiazepine -tolerant
What is akathisia?
`Akathisia is a sense of inner restlessness and inability to keep still
