WK 10- Psychiatric Emergencies Flashcards
What is the SADPERSONS scale
-what does it assess
Assesses suicide risk
-Initially straight up ask if they are contemplating suicide
S→ Sex; females are more likely to attempt suicide, but males are more likely to choose a deadly means
A→ Age; 15-24 year olds or men 75 and older are at risk
D→ Depression
P→ Previous Attempts
E→ Ethanol (alcohol) and other drug use
R→ Rational thinking loss
S→ Social support lacking
O→ Organised plan→ the more specific the greater the risk
N→ No spouse/ or suicide in the family
S→ Sickness
→ also straight up ask whether they have thought of suicide
What are the 4 components of a mental health assessment
History and Corroborative History
Mental State Examination (MSE)
Physical Examination
Investigations
What is looked for in a mental state exam
-MSE:
A= appearance and behaviour→
Clothing - appropriate to climate & culture, clean, torn
Grooming - unkempt, well groomed, odorous
Posture - slumped, rigid, upright
Eye contact - good, avoiding, limited
Facial expression - sad, animated, anxious
Motor activity - decreased, increased, lethargic
Reaction to interviewer - hostile, withdrawn, co-operative, guarded, uncommunicative.
S= speech (tone and volume, rate, rhythm)
Rate- normal, accelerated, slow, pressured
Volume/tone – quiet, loud, whispered
Quantity – poverty of speech, monosyllabic, excessive
Continuity – can the person maintain a normal progression from one stream of thought to the next
E= emotion (mood and affect→ affect is what you observe at the moment, mood is how the patient describes how they have been feeling)
P= perceptions (hallucinations and illusions)
T= thoughts (form and content- illogical? Delusions (multiple types→ grandoid (thinking they are great/have powers, paranoid (think people are following him)? loosely associations (jump from topic to topic without logical progression), fears)
I= Insight/Judgement
Insight – aware they have a problem
Partial insight – aware they have a problem but believe someone else is responsible
No insight – denies problem
Judgment – ability to measure consequences of actions
C= cognition (memory, thought processes)
What is the MOA of midazolam -what class does it belong to
interact with the gamma-aminobutyric acid (GABA)-benzodiazepine receptor complex, which is widespread in the brain
-Midazolam binds to the GABA receptor but does not displace GABA→ enhances the affinity of GABA for its receptor site on the same receptor complex→ the pharmacodynamic consequences of benzodiazepine agonist actions include antianxiety effects, sedation, and reduction of seizure activity.
Why is midazolam useful in treating acutely disturbed patients
has a fast absorption rate meaning the effects have rapid onset
- Can be delivered IV, IM, SC or oral
- Large therapeutic index
What is the MOA of olanzepine
Act by preventing re-uptake of noradrenaline and serotonin, by blocking serotonin and NA
transporters.
-Also has anti cholinergic effects.
-Therapeutic onset slow-7-14 days
-Also act as Na channel and Ca channel blockers
What are the signs of a midazolam overdose
Signs of overdose include sedation, somnolence, confusion, impaired coordination, diminished reflexes, coma, and deleterious effects on vital signs.
What are the signs of an olanzepine overdose
tachycardia, agitation, dysarthria, decreased consciousness and coma.
-is a tricyclic
What is delirium
is the organic cause of confusion
- most commonly appears in the elderly
- most commonly caused by infections–> such as UTI
- has an acute onset
How can you differentiate between delirium and dementia
delerium= acute rapid onset dementia= gradual slow onset
What are the most common causes of organic causes of diseases
- Infection→ UTI, Pneumonia (hypoxia)
- Trauma→ causing hypovolemic shock and hypoperfusion of the brain
- Drug induced psychosis/withdrawal → in withdrawal the hallucinations are tactile (you can feel things like ants, and are often visual→ can see things)
- Metabolic= hypoglycaemia, acidosis, hypothyroidism/hyperthyroidism, hypocalcemia, hyponatremia
- Tumour→ glioblastoma
- Vascular→ Stroke, Subarachnoid haemorrhage
- Autoimmune→ lupus, vasculitis
- Post-ictal confusion (after seizure confusion)
If a pt is hearing voices, is it most likely drug induced or psychosis
Psychotic hallucinations are auditory
-hallucinations caused by alcohol/drug withdrawal are often tactile and visual
What is the guardianship at
→ allows involuntary treatment of patient who is incompetent to make decisions or risk to self or others →due to a medical problem (ie. Head trauma)
→ you are able to keep the person in the ED if you believe they may be at risk of harm
-anyone can be legally covered by the act→ guardianship allows you to treat them without consent
What is the mental health act
Mental health act:
-Allows involuntary holding of a patient who is
incompetent or risk to self of others due to a psychiatric problem (allows you to keep them (hold them) in the ED)
-need to suspect there is a mental illness and as a result they are incompetent
-needs 2 people to complete the R+R→ request (anyone except an employee or family member), recommendation (doctor, can’t be family)
What are the 6 involuntary assessment criteria needed for R+R (referral or recommendation)
-Mental illness suspected
-Risk to self or others
-Not competent due to a mental illness
-No less restrictive way = pt refusing to stay
-Approved mental health facility available
-Needs immediate assessment
NB. R+R allows to lock patient in a room, but to give them sedation comes under Guardianship Act/Duty of care.
What is required in order to medically clear someone
Medical clearance is to exclude organic causes of confusion/agitation
-need to have normal vitals, normal neurology, no evidence of trauma, normal investigations (ie. normal septic screen, CT head, thyroid)
A 20 year old is brought in by police, drowsy and confused. She has a temperature of 39.5 degrees C. What is the most likely cause of her confusion
- Acute schizophrenia
- Acute mania
- CNS infection
- Alcohol intoxication
CNS infection
A 20 year old is brought in by police, confused and agitated. P 140, BP 180/110. What is the likely cause of his confusion?
- Alcohol intoxication
- Acute psychosis
- Hypertensive encephalopathy
- Drug ingestion
-Drug ingestion–> most likely amphetamines
A 20 year old is brought in by police, confused and agitated. The voices are telling him to direct the cars off a bridge. What is the likely cause?
- Acute psychosis
- Acute drug ingestion
- Alcohol intoxication
- Personality disorder
Acute psychosis
An elderly man is brought in by police, lost and wandering. He has no idea where he lives. Temp 38 degrees C. What is the likely diagnosis?
- Alcohol intoxication
- Acute psychosis
- Delirium
- Dementia
Delerium
An elderly man is brought in from the park. He is very dishevelled and dirty. He sees ants and snakes crawling all over him. (There aren’t any!) What is the likely diagnosis?
- Acute alcohol withdrawal
- Acute alcohol intoxication
- Psychosis
- Depression
-Acute alcohol withdrawal
An elderly man is brought in by police. He is accusing the neighbours of poisoning his cat and his dog. (they didn’t) His observations are all normal and he is alert and oriented. What is the likely diagnosis?
- Alcohol intoxication
- Depression
- Acute psychosis
- Delirium
-Acute psychosis
An elderly man attends ED with confusion. Which of the following factors would suggest a psychiatric cause?
- Alcoholism
- Loss of memory
- Disorientation
- Delusions
Delusions
An elderly man attends ED. Which of the following factors would suggest delirium?
- Disorientation
- Memory loss
- Delusions
- Auditory hallucinations
-Disorientation
A 40 year old woman comes in with acute paranoid ideation. She has a past history of Ca Breast. Neurological exam is normal apart from the paranoid ideation. What investigations does she need?
- No investigations as neuro exam is in effect normal
- She only needs routine blood tests to exclude and organic cause
- She needs an urgent MRI to exclude CNS pathology
- She should have an urgent CT to exclude CNS mets
-She should have an urgent CT to exclude CNS mets
A 70 year old man is brought in by police after an apparent suicide attempt. Which factor would suggest an increased risk of suicide?
- Overdose taken in a quiet location but patient found unexpectedly
- Patient has good social supports
- Patient took a very harmful drug (digoxin)
- Patient has a history of many similar previous attempts
-Overdose taken in a quiet location but patient found unexpectedly
What other factor would have the greatest effect on increased risk of suicide
- Underlying psychosis
- Divorce
- Lack of social support
- Alcohol use
Underlying psychosis
A 20 year old is brought in by police. He was trying to jump in front of cars on the freeway. He is expressing suicidal ideation and has a plan to walk off the motorway overpass tonight. He is now trying to leave. What will you do?
- Let him leave. It would be unethical to treat him against his will.
- Fill out R&R paperwork, as it would be unethical to let him go.
- Sedate him so that he cannot leave
- Send him out with the police so that he will be safe
-Fill out R&R paperwork, as it would be unethical to let him go.
What is the difference between psychosis and delirium
‘psychosis’ = loss of connection with reality (mental illness) ‘delirium’ = loss of connection with reality with confusion from medical / organic cause
