Mental health in the Emergency Department

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A basic overview for emergency department nurses on managing mental health presentations.

Transcript of Mental health in the Emergency Department

  • 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
  • EDs 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 Huntingtons 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 LSD Withdrawal: Alcohol Benzos
  • 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 consciousness Memory: 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 illnesss
  • 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 Benzos 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 Dont 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 dont 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