mental health in the emergency department
DESCRIPTION
A basic overview for emergency department nurses on managing mental health presentations.TRANSCRIPT
Mental Health in the EDKane Guthrie
Learning Points
Overview of MH in ED Basic Mental Health Assessment Managing common disorders
Psych Resources in ED
24/7 Duty PLN & Psych Registrar 24/7 Oncall Psych Consultant Social worker Drug & Alcohol nurse SHACCS
ED’s Role
Stabilise aroused/frightened patient Manage acute behavioural disturbances Excluded medical causes Determine need for voluntary vs involuntary Arranging referral/disposition Family/carer support
Brief Assessment
Circumstances of referral /Presenting problem Social circumstances Previous treatment /Current mental health
service ETOH & drug use Mental state exam Medical/Risk assessment & investigations Provisional Dx Treatment & disposition
Medically Clearance
Contentious issue “Fit for psychiatric evaluation”
High risk: First time presenters Failure to take Hx Poor attention vital signs/ physical Ax
Screening for Medical Cause
Vital signs:Consider (case specific) FBC, U&E, TFT Paracetamol level ECG Urinalysis +/- Head CT/MRI +/- LP
Medical causes of Psychosis Epilepsy Hypo/hyper thyroidism Huntington’s disease Porphyria B12 deficiency Cerebral neoplasm Stroke Viral encephalitis AIDS Neurosyphillis
Medical causes Depressive symptoms
Hyperthyroidism Hypercalcaemia Pernicious anaemia Pancreatic Ca Lung ca Dementia
Drug Abuse = Psychosis
Amphetamines Cocaine PCP LSDWithdrawal: Alcohol Benzo’s
Mental State Exam
Mental State Exam
Appearance & Behaviour Speech Mood & Affect Form of thought Content of thought Perception Sensorium & Cognition Insight
Appearance & Behaviour
Appearance: Grooming, posture, clothing, build
Behaviour: Eye contact, cooperativeness Motor activity Abnormality of movement Expressive gestures
Speech
Articulation disturbances Rate Volume
Quantity of information: Pressured Loud Slurred Mumbled
Mood & Affect
Mood: Depressed, euphoric, suspiciousness
Affect: Restricted, flattened, inappropriate
Form of Thought
Amount of thought Rate of production
Flight of ideas Derailment
Continuity of ideas Disturbance in language & meaning
Content of Thought
Suicidal/ homicidal thoughts Delusions
A belief held with strong conviction despite evidence to the contrary.
Overvalued ideas, obsessions, phobias
Perception
Hallucinations A perception in the absence of apparent
stimulus that has qualities of real perception. Other perceptual disturbances:
Derealisation Depersonalisation Illusions
Sensorium & Cognition
Level of consciousnessMemory:
Immediate, recent, remote
Orientation: Time, place, person
Insight
Capacity to understand:
Own symptoms/illness Knowledge of medications Amenable to treatment Likelihood of compliance treatment
Documentation
NAB HECTOR• Name• Age• Build
Height Eyes Complexion Thatch (hair) Oddities (scars,
tattoos, deformities) Rig (clothing)
Suicide
Patients often prevent suicidal Overdose Self harm Plan
ED role Risk assessment Prevent suicide Offer support/disposition
Why do people self harm?
Significant proportion intend to die Escape intolerable situation No clear explanation “Loosing control” Punish someone “makes others feel guilty” Excess of life events
Bereavement Job loss Financial difficulties
Risk Factors for Suicide
Being single, divorced, widowed Unemployed Recent life stresses Having mental illness Previous self harm Substance abuse problem
Duty of Care
Duty of care needs to be enacted when: Risk to self (suicidal) Risk to others (homicidal) Under command auditory hallucinations Lack insight/capacity
The Big 5 Disorders
Depression Anxiety Bipolar Disorder Psychosis/Schizophrenia Borderline personality disorder
Case 1
55 male Wife left him Lost Job Increasing ETOH consumption
BIBP after calling mate saying was going to hang himself
Depression
Can be: Acute major depressive Chronic (dysthymia)
Affects 3-5% worlds population “Serotonin depletion”
Characteristics
Physical symptoms: Fatigue Nausea Headaches
ED Management
Kindness and reassurance Ensure patient safety (contain till risk Ax) Explore suicidal ideation Psych disposition (Admit vs O/P follow up) Antidepressant may be started in ED
SSRI or SNRI
Case 2
19 female Presents with palpitations/nausea Hyperventilating “I'm going to die”Social Hx: Doing uni exams Found out BF kissed another girl
Anxiety
More difficult emotion to handle: Compared to anger/depression
Cascade of symptoms often overwhelming Strong component of other psychiatric
illness’s
Panic/Anxiety Attacks
Overwhelming sense fear/doom Uncooperative/Irrational Often unable to process what is being said to
them
Characterised
Physical: Nausea Chest pain Shortness of breath Dizziness Headache
ED Management
Explore/rule out physical symptoms Listen & reassure Arrange follow up Benzo’s have limited role Antidepressants may help Coping techniques
Case 3
47 male Presents rambling Trashed house after loosing 5k at casino Hx of depression States all is find then goes of on tangents
Bipolar Disorder
aka- Manic depressive illness Disruption in brain chemistry Major mood swings
Characteristics
Extreme mood swings/behaviours Mania severe depression
Mania Grandiose Delusional thinking Rapid pressured speech Impulsive risk behaviours
ED Management
Low stimulus Keep directions/statements short simple
Medicate for agitation Assume unpredictable Often will require admission during acute
episode Lithium/Carbamazepine long term
Case 4
22 male Presents paranoid
Aliens & space ships are following him” Refusing to engage at triage
?hx of amphetamine use
Psychosis
Characterised by: Delusional Hallucinations Disorganisation of thinking
Psychosis vs Schizophrenia
Psychosis: Short term Drug induced or medical induced
Schizophrenia: Disruption in brain chemistry Onset typically adolescents/young adults
ED Management
Ensure safety Don’t feed into delusions Ask about voices/visual hallucinations Provide low stimulus environment Medicate for agitation
Case 5
26 female Presents with DSH to foramen/ paracetamol
OD 5th presentation in 5 weeks Hx of PTSD- child abuse Refuse's to cooperate Abusing staff – you don’t understand
Borderline Personality Disorder
Rigid fixed perception – world Often in pts with traumatic childhoods Extreme fear abandonment
Characteristics
Chaotic relationships Intense reactions to situations Dramatic-manipulative behaviours Attention seeking behaviour Self harm – manage intense feelings Often chronically suicidal
ED Management
Avoid power struggles Avoid punitive treatments, ultimatums Often require short period containment Medicate as appropriate to control behaviour Prepare for high risk behaviour (Self, others)
Questions
Take Home Points
Know the resources available These patients can be confronting Learn an approach Most are not violent Always ensure safety first yourself then your
patient
Thank You