Psychiatric emergencies Flashcards
How are psychiatric emergencies classified?
major, minor and emergenices related to medical causes Around 30% of emergency patients are suicidal, 10% are violent, 40% require hospital admission Major: Suicidal Agitated and violent Minor: Grief reaction Rape Disaster Panic attack
What are common medical emergencies?
Delirium Neuroleptic malignant syndrome Serotonin syndrome OD of common psychiatric medications OD and withdrawal from addicting substance
Whta is delirium?
Transient, potentially reversible cerebral dysfunction with acute or subacute onset that manifest with fluctuating mental state abnormalities
Global cognitive impairment associated with behavioural abnormalities
10-30%
10-15% elderly people admitted to hospital, another 10-40% develop it during their stay
60% of delirium is superimposed on dementia
Due to alterations in Ch or NA neurotransmitter systems, or interruption of the BBB
What is the ICD-10 criteria for delirium?
Clouding of consciousness- reduced awareness of environment, reduced focus, shifting attention
Disturbed cognition- Impaired immediate recall and recent memory disorientation in time, place or person
Variable anxiety levels, increased reaction time, altered speech flow, enhanced starlet reaction
Insomnia, daytime drowsiness, reversed sleep-wake cycle, disturbing dreams/nightmares
What are the types of delirium?
Hyperactive- heightened arousal, restless, agitated aggressive Hypoactive- withdrawn, quiet, sleepy Mixed Delirium superimposed on dementia persistent delirium
What are raw causes of delirium?
INFECTION - HIV, Sepsis, pneumonia
WITHDRAWAL - alcohol, barbiturates, sedatives
ACUTE METABOLIC - acidosis, alkalosis, electrolyte imbalance, hepatic failure, renal
failure
TRAUMA - head injury, heat stroke, post-op, severe burns
CNS PATHOLOGY - abscess, haemorrhage, SDH, stroke, seizures, tumours,
meningitis, encephalitis, syphilis
HYPOXIA - anaemia, CO poisoning, hypotension, CCF
DEFICIENCIES - B12, folate, niacin, thiamine
ENDOCRINE - hyper/hypoadrenocorticism, hyper/hypoglycaemia, hyperparathroid
ACUTE VASCULAR - hypertensive encephalopathy, stroke, arrhythmia, shock
TOXINS/DRUGS - illicit, prescription, solvents
HEAVY METALS - lead, managnese, mercury
What is the assessment for delirium?
History - patient, collateral and notes Consider physical causes - infection, constipation, dehydration, medications, alcohol withdrawal Risk assessment Complete a BASELINE MoCA
What are the investigations for delirium?
Infection - culture, urinalysis, FBC, CRP, CXR Medication review Metabolic/endocrine Cardiac - ECG Hypoxia - ABGs Neuro - CT brain
What is the management for delirium?
Identify and treat precipitating cause
Provide a calm environment and supportive measures
Involve family and carer
May refer to psychiatric team
Avoid sedation unless severely agitated
Review patient regularly
Prognosis- average duration is 7 days, increased risk of mortality- increased by 75% in elderly population
What is acute behavioural disturbance?
Develop in patients with mental health illnesses at any time in the course of their illness, or as a manifestation of an underlying organic illness
Patients become agitated/aggressive during an acute episode of illness, eg mania/schizophrenia
- May be due to psychotic symptoms
- Due to non-psychotic symptoms
- Use of illicit drugs
What are the basic principles of acute behavioural disturbance?
Predictions of risk of agitation
Prevention of behaviour escalating once patient becomes disturbed
Use interventions to ensure safety of patients and staff
What are the warning signs for an increased risk of aggression?
Persecutory delusions Delusions of passivity Actual threats of violence Emotional state linked to violence Behaviour Limited insight
What are the warning signs for violent behaviour?
Angry facial expression Restless or pacing Shouting Prolonged eye contact Refusal to cooperate delusions/hallucinations with violent content Verbal threats/thoughts of violence Blocking escape routes Evidence of arousal - SNS activation
How should physical restraint be carried out?
Only used when other measures have failed/inappropriate
One member of staff should be in charge and carry out:
Encourage patient to move to a separate room/area
Speak confidently, slowly and clearly
Adopt a non-threatening body posture and verbal communication
Pre-warn the patient
Explore concerns
Develop a rapport with patient
Request patient to put any weapons down
What should be considered when giving rapid tranquillisation?
Calm the patient without sedating them and reduce risk of violence and harm
Give orally where possible
Always consult a senior doctor
Use minimum dose of medications
Choose one with a rapid onset, short-acting, minimal side-effects and easily reversible effects
