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Mental health in the Emergency Department
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Mental health in the Emergency Department

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

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

Published in Health & Medicine
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  • 1. Learning Points  Overview of MH in ED  Basic Mental Health Assessment  Managing common disorders
  • 2. Psych Resources in ED  24/7 Duty PLN & Psych Registrar  24/7 Oncall Psych Consultant  Social worker  Drug & Alcohol nurse  SHACCS
  • 3. 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
  • 4. 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
  • 5. Medically Clearance  Contentious issue  “Fit for psychiatric evaluation”  High risk:  First time presenters  Failure to take Hx  Poor attention vital signs/ physical Ax
  • 6. Screening for Medical Cause  Vital signs: Consider (case specific)  FBC, U&E, TFT  Paracetamol level  ECG  Urinalysis  +/- Head CT/MRI  +/- LP
  • 7. Medical causes of Psychosis  Epilepsy  Hypo/hyper thyroidism  Huntington’s disease  Porphyria  B12 deficiency  Cerebral neoplasm  Stroke  Viral encephalitis  AIDS  Neurosyphillis
  • 8. Medical causes Depressive symptoms  Hyperthyroidism  Hypercalcaemia  Pernicious anaemia  Pancreatic Ca  Lung ca  Dementia
  • 9. Drug Abuse = Psychosis  Amphetamines  Cocaine  PCP  LSD Withdrawal:  Alcohol  Benzo’s
  • 10. Mental State Exam
  • 11. Mental State Exam  Appearance & Behaviour  Speech  Mood & Affect  Form of thought  Content of thought  Perception  Sensorium & Cognition  Insight
  • 12. Appearance & Behaviour Appearance:  Grooming, posture, clothing, build Behaviour:  Eye contact, cooperativeness  Motor activity  Abnormality of movement  Expressive gestures
  • 13. Speech  Articulation disturbances  Rate  Volume  Quantity of information:  Pressured  Loud  Slurred  Mumbled
  • 14. Mood & Affect Mood:  Depressed, euphoric, suspiciousness Affect:  Restricted, flattened, inappropriate
  • 15. Form of Thought  Amount of thought  Rate of production  Flight of ideas  Derailment  Continuity of ideas  Disturbance in language & meaning
  • 16. Content of Thought  Suicidal/ homicidal thoughts  Delusions  A belief held with strong conviction despite evidence to the contrary.  Overvalued ideas, obsessions, phobias
  • 17. Perception  Hallucinations  A perception in the absence of apparent stimulus that has qualities of real perception.  Other perceptual disturbances:  Derealisation  Depersonalisation  Illusions
  • 18. Sensorium & Cognition  Level of consciousness Memory:  Immediate, recent, remote Orientation:  Time, place, person
  • 19. Insight  Capacity to understand:  Own symptoms/illness  Knowledge of medications  Amenable to treatment  Likelihood of compliance treatment
  • 20. Documentation NAB HECTOR • Name • Age • Build  Height  Eyes  Complexion  Thatch (hair)  Oddities (scars, tattoos, deformities)  Rig (clothing)
  • 21. Suicide  Patients often prevent suicidal  Overdose  Self harm  Plan  ED role  Risk assessment  Prevent suicide  Offer support/disposition
  • 22. 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
  • 23. Risk Factors for Suicide  Being single, divorced, widowed  Unemployed  Recent life stresses  Having mental illness  Previous self harm  Substance abuse problem
  • 24. 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
  • 25. The Big 5 Disorders  Depression  Anxiety  Bipolar Disorder  Psychosis/Schizophrenia  Borderline personality disorder
  • 26. Case 1  55 male  Wife left him  Lost Job  Increasing ETOH consumption  BIBP after calling mate saying was going to hang himself
  • 27. Depression Can be:  Acute major depressive  Chronic (dysthymia)  Affects 3-5% worlds population  “Serotonin depletion”
  • 28. Characteristics Physical symptoms:  Fatigue  Nausea  Headaches
  • 29. 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
  • 30. 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
  • 31. Anxiety  More difficult emotion to handle:  Compared to anger/depression  Cascade of symptoms often overwhelming  Strong component of other psychiatric illness’s
  • 32. Panic/Anxiety Attacks  Overwhelming sense fear/doom  Uncooperative/Irrational  Often unable to process what is being said to them
  • 33. Characterised Physical:  Nausea  Chest pain  Shortness of breath  Dizziness  Headache
  • 34. ED Management  Explore/rule out physical symptoms  Listen & reassure  Arrange follow up  Benzo’s have limited role  Antidepressants may help  Coping techniques
  • 35. 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
  • 36. Bipolar Disorder  aka- Manic depressive illness  Disruption in brain chemistry  Major mood swings
  • 37. Characteristics  Extreme mood swings/behaviours  Mania severe depression Mania  Grandiose  Delusional thinking  Rapid pressured speech  Impulsive risk behaviours
  • 38. 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
  • 39. Case 4  22 male  Presents paranoid  Aliens & space ships are following him”  Refusing to engage at triage  ?hx of amphetamine use
  • 40. Psychosis Characterised by:  Delusional  Hallucinations  Disorganisation of thinking
  • 41. Psychosis vs Schizophrenia Psychosis:  Short term  Drug induced or medical induced Schizophrenia:  Disruption in brain chemistry  Onset typically adolescents/young adults
  • 42. ED Management  Ensure safety  Don’t feed into delusions  Ask about voices/visual hallucinations  Provide low stimulus environment  Medicate for agitation
  • 43. 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
  • 44. Borderline Personality Disorder  Rigid fixed perception – world  Often in pts with traumatic childhoods  Extreme fear abandonment
  • 45. Characteristics  Chaotic relationships  Intense reactions to situations  Dramatic-manipulative behaviours  Attention seeking behaviour  Self harm – manage intense feelings  Often chronically suicidal
  • 46. 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)
  • 47. Questions
  • 48. 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
  • 49. Thank You