Psych Emergencies

Question 1

ECT indications

Answer 1

Severe depression associated with psychosis and suicide risk.
Psychomotor stupor or catatonia
Life-threatening insufficiency of fluid and food due to the above
Treatment-resistant depression
Treatment-resistant mania
Treatment-resistant schizophrenia
Treatment is urgently required and appropriate medication of contraindicated

Question 2

Approach to violent patient

Answer 2

Prevention
-Recognise symptoms or and behaviour that might suggest escalation to violence
-remove sharp objects and furniture
Take history (collateral):
-non-medical
-known medical and psychiatric history
-substance abuse and/or dependence
Steps to manage violence
1. De-escalation
Verbal intervention to diffuse a potentially violent or aggressive situation, to prevent physical restraint use. Done by
-assessing the situation
-communicating to facilitate co-operation and problem-solving
-calm and non-threatening
-open-ended questions
-managing the environment
-attempting rapport
2. Physical Restraint
-only if acutely dangerous
-not any physical injuries
-inform and sedate patient
-requires a 5 point restraint- 1 leader and 4 assistants, the team should be coordinated
3. Sedation
-orally by can do IV/IM
Oral- haloperidol or chlorpromazine
IV/IM: haloperidol, olanzapine, lorazepam
4. Mechanical Restraint
-for safety of patient while waiting for sedation
-less than 30min fill in form MHCA 38
5. Post sedation/ Seclusion/Transfer
-short-term seclusion after filling MHCA 48
-observe vitals 5-10 minutes for first hour and then 15 minutes
-treat any noted issues
-transfer to psychiatric unit for 72 hrs involuntary

Question 3

NMS clinical presentations and management

Answer 3

Clinical presentation:
Fever
Autonomic dysregulation
Rigidity
Mental State change: delirium
Management:
Stop antipsychotics
Admit
Monitor vitals
Cooling and hydration
Medication:
Benzodiazepines: lorazepam
Dantrolene
Bromocriptine
ECT if not working
Rechallenge with SGA

Question 4

Alcohol Withdrawal symptoms and management

Answer 4

3-12: SNIP(H)
Shakiness, nausea, irritability, perceptual disturbances including hallucinations
12-18: AAS(G)
Increased agitation, autonomic changes, generalised seizures
48-72: DAAD
Delirium tremens (disorientation, hallucinations, tachycardia, hypertension and agitation), altered LOC, autonomic hyperactivity, disorganised behaviour

Management
Moderate to severe, >50, hx of seizures
Close observations: BP, T, RR, LOC
Fluid replacement: 5% dextrose
Vitamin supplements: Thiamine and multivitamin
Sedation or phenobarbital or propofol
Monitor and investigate complications
- bleeding
-wernicke encephalopathy: delirium, unsteadiness and eye movement changes
Organise follow-up
Plan rehabilitation

Question 5

Role of Mental Health Review Board

Answer 5

Independent body:
-ensure that the steps followed to assist a psychiatric patient are according to the MHCA 17 2002
-ensure all procedures are followed
-check all forms are completed correctly form 13
-provide legal assistance to patients
-make sure that patients are not detained erroneously
-review patient appeal form 15 -confirm receipt within 7 days have to seen to see patient within 30

Question 6

Involuntary Admission

Answer 6

Form 4: founding affidavit
Completed to apply for involuntary care, treatment and rehabilitation.
Completed by spouse, partner, parent guardian or someone with parental right and responsibilities or someone who knows and sees patient daily
If <18 and the above is incapable, unwilling and unavailable after trying all means than Head of the health establishment completes form
>18 and the above is incapable, unwilling and unavailable after trying all means than a mental health care worker can complete this form
An oath is taken and commissioned
Once commissioned the patient has to present within 2 days
Form 5: examination and continue application for involuntary care, treatment and rehabilitation
Completed by 2 independent mental health care workers where both must be able to complete a mental state exam and at least 1 qualified to also conduct a physical examination.
Form 7: the decision to commence 72 hour assessment
Completed by HHE, HHE checks if assessment concur or differ, if concern than this form is signed and the 72-hour starts. Must be with 48hrs after the MHCA
Form 6: findings after completion of the 72 hour assessment
Completed within 12hrs after expiration of 72 hour involuntary assessment.
Completed by 2 independent mental health care workers where both must be able to complete a mental state exam and at least 1 qualified to also conduct a physical examination.
Form 8: if continued in-patient is required
Completed by HHE within 24 hrs after expiration of involuntary 72 hour assessment
Form 9: if involuntary outpatient care is needed completed by HHE with form 10 also completed for the transfer also by HHE
Form 3: discharge
Form1: emergency care (24hrs)
Form 11: transfer to another in-patient MHCU