Background - Psychiatric Emergency
As an Emergency Medicine doctor, violence, drug abuse, alcoholism, psychoses, suicide attempts, confusional states and plain human distress and fear will confront you frequently. You may feel inadequate, frightened, impatient or irritated by such patients. Nurses, receptionists and porters will also be involved and will look to you for advice and support. Anxious, fearful or aggressive relatives and friends will need tactful handling and Gardaí and social workers will be seeking someone to take the patient off their hands. In a busy department there will be pressures to cope with many other emergencies and time to deal with the psychiatric problem will be at a premium. A reassuring, orderly, calm approach will save time in the long run.
As comprehensive a history as possible must be obtained from the patient, his relatives, friends, the Gardaí, social workers and ambulancemen. A telephone call to the GP may save hours of detective work. This should be followed by a physical and mental state examination, even though it may be difficult to obtain full co-operation.
You should record any difficulties experienced in taking a history or making the examination.
However tired or harassed, avoid a brisk authoritarian or patronising attitude. Introduce yourself by name, and address the patient courteously by name. Do not use first name.
Whatever the patient may be saying, emphasis on how one can be of help should be stressed.
Gentle physical contact may be helpful if one is not alone with the patient, such as touching the arm, or feeling a pulse.
Remember, the patient is likely to be much more worried and frightened than you are.
History and examination is best carried out in a quiet room. Whatever the sex of the doctor or patient it is as well to have a nurse present and possibly a relative or friend if the patient wishes it. Explain each stage of physical examination, "I'm just going to shine a light in your eyes" or "I'm taking your blood pressure with a tight cuff around your arm", without treating the patient like a child. Avoid unpleasant and undignified examinations, such as p.r. or p.v., if they are unlikely to yield information of immediate importance. Note particularly:
- state of personal hygiene and clothing
- smell of alcohol
- scars, tattoo marks, bruises, wounds and injection marks
- state of nutrition and hydration
Mental state examination
|Level of consciousness||Alert or Drowsy|
|Appearance and behaviour||Degree of co-operation, under or over dignity, overbreathing, suspiciousness, hostility, muttering, posture, tearful, eye contact|
|Speech||Coherence, pressure or slowing of speech|
|Mood||Anxiety, Depression, Elation, Anger, Fearfulness, Lability, Appetite, Concentration, Sleep problems, Suicide ideation|
|Thought content||? repetitive thoughts, ? interference with thoughts|
|Perceptions||? hallucinations esp auditory or visual|
|Cognitive function||Memory for recent and remote events, Orientated T,P,P.|
|Short term recall||Recall a fictitious address etc.|
It is important that good notes should be made at the time of the examination.
Objects of assessment
The EM doctor's responsibility is to make an appraisal of a crisis situation and institute appropriate management and eventual disposal. When confronted by the distressed, confused or behaviourally disturbed patient it will be important to answer the following questions:
- Is organic disease or trauma responsible for the disorder? If the patient shows disorientation, memory disturbance, visual hallucinations, fluctuating levels of consciousness, it is likely that organic disease, trauma or drug intoxication or withdrawal is present.
- Does the patient require admission to a medical or surgical ward for further observation and treatment?
- Is the patient a danger to himself or others? He may be expressing suicidal ideas (or they may be elicited), homicidal feelings or intentions, or behaving aggressively.
- Does the patient require admission to a psychiatric unit, either informally or under a section of the Mental Treatment Act ?
- In what social context has the disturbance occurred and how far can relatives and friends be helped to cope with the situation?
Patients presenting with deliberate self harm
Overdoses of varying degrees of seriousness, cut wrists and throats, burns, drowning, hanging, poisoning will all be present in the category of "para-suicide". Many may be associated with the smell of alcohol on the breath. When confronted by such a patient it is safer to assume that all are, may lately have been, or may still be genuinely intent on self-destruction. In any event, all of them are seeking help.
In practice an ED Officer will not have to deal with the psychiatric problem if the self-damage is sufficiently great to warrant admission for medical or surgical treatment. It is the minor overdose, the superficially cut wrist, or the patient who says he feels suicidal that will pose the immediate psychiatric management problem. Such patients may be no less potentially suicidal than the one who has severed his brachial artery.
REMEMBER that some patients may use more than one method of self-harm. For example, the girl who has a minor cut to her wrist may also have taken a large dose of aspirin.
Assessment of patient
A decision will need to be reached as to whether the patient requires:
(a) medical admission,
(b) psychiatric admission,
(c) further psychiatric assessment as an outpatient,
(d) social work counselling.
If suicidal ideas are associated with symptoms of severe depression such as ideas of hopelessness, guilt, slowing up, early waking and weight loss, admission may be required.
If associated with schizophrenia and particularly persecutory voices and delusions, the patient may need to be admitted.
If suicidal ideas occur in the puerperium admission may be required and immediate psychiatric and social assessment will be needed (see section on The Post-Natal Patient).
The majority of minor acts of self-damage will be in response to a social crisis. Whatever may appear to be the reason for the suicidal attempt or idea the circumstances of any attempt must be explored to determine the seriousness of intent.
- Was the patient alone and unlikely to be found?
- Was the act premeditated or a suicidal note left?
- Did he think the act would kill him?
- Did he want to die?
Affirmative answers all imply serious intent. Even if the patient denies any desire to make a further suicide attempt, if the intent appears to have been high admission should be considered and certainly the patient should be examined or the case discussed with a psychiatrist.
Patients should be admitted overnight, for a formal psychosocial assessment by the psychiatric liaison team. Patients regarded as high risk of further by experienced ED staff should be assessed urgently by the on call psychiatry team, not held until the following morning.
Referred to plastic surgery CUH
All patients who have had deliberate self-harm should have a psychosocial assessment by a trained assessor as early as possible following the episode.
In most centres this assessor will be the psychiatrist on-call to the local Emergency Department.
Prior to accepting a referral of a patient following deliberate self-harm to CUH for a plastic surgery assessment or intervention, the surgical team should ensure the following:
- The patient has had a psychosocial / risk assessment by the local psychiatrist on-call.
- The outcome of this assessment has included inter alia clear recommendations about:
- Supervision arrangements
- Contingency planning during transport to CUH
- The need for special (1:1) nursing during CUH stay
- The level of urgency of the need for further psychiatric assessment in CUH
A written copy / summary of the psychosocial assessment is included with the surgical transfer letter that accompanies the patient to CUH. Agreed gudelines
The violent patient
Violent or assaultive behaviour is no more common in the mentally ill than in the general population and is not necessarily a psychiatric problem. Most violence encountered in the ED is the result of alcohol intoxication.A conscious effort must be made to avoid provocation by a rebuke or rough handling.
Definition - aggression is an act or gesture, verbal or physical, which suggests that an act of violence may occur. The signs and symptoms are many and varied but include the following:
- tension and agitation
- abrupt replies to questions with gesticulations and an increase in the pitch and volume of the voice
- signs of tension in the face and limbs with clenching of the fist or striking of the hand. The pupils may be dilated.
A patient may sit in a crouched posture in silence resenting communication and refusing to answer questions until a chance remark may trigger off sudden and dangerous violence.
Prevention is the first priority and should concentrate on gaining the patient's trust and confidence. Frustration may result from anger, fear, despair, confusion or a perceived threat.
Suppress your personal feelings. Stay calm, confident, objective, non-critical and non-domineering.
Physical confrontation should only take place as a last resort. Try listening or talking to the patient, choosing the team member that has the best relationship, and do not argue. Relatives may assist.
Do not approach a violent patient on your own and ensure that sufficient staff are available to control the patient if necessary. Do not position yourself in a way which allows an easy physical attack.
Damaged property is relatively unimportant but damage to the individual is.
The degree of force used should be the minimum required and used to calm rather than provoke further aggression.
If the patient has to be restrained, remember:
- that he may be pinioned with the arms to the side by means of a bear-hug from behind and wrestled to the floor if necessary by lying across him.
- do not apply pressure to the neck, throat, chest or abdomen.
- grasp clothing in preference to limbs. If limbs have to be held, do so near the major joints to reduce the chance of fracture or dislocation.
- remove boots or shoes from the patient as soon as possible. Wrapping in a blanket might help.
- if possible, move and segregate the patient in a quieter environment.
- if possible remove furniture to prevent the patient sustaining harm.
- placing the patient on the floor puts him at a disadvantage.
Patients should not be reproached for previous actions.
The malingering patient
If a patient complains of symptoms or shows disturbed behaviour it is unwise to assume that the disorder is simulated until one is quite sure that he/she is not suffering from a physical or psychiatric illness. In the relatively rare cases of true malingering one may have to give the benefit of the doubt at the time of the contrived crisis. Occasionally, stupor or mutism may be stimulated, but generally the presentation will be with physical symptoms, suggesting cardiac, abdominal or neurological disease. Physical signs may be elicited, but will probably be untypical or contradictory.
Drug addicts may complain of severe pain, suggesting cardiac, renal or abdominal disease in order to obtain opioids.
- Vagrants (who may be alcoholic, schizophrenic or personality disordered) may simulate disease when seeking a bed for the night.
- People in trouble with the Gardaí, or anticipating it, may find a hospital a good place to hide for a while.
- The Munchausen Syndrome patient may be a great drain on hospital resources. Although well publicised, such patients are uncommon. They suffer from a personality disorder and seem to gain satisfaction from not only simulating disease, but from undergoing unpleasant invasive investigations and even operations. Their abdomen may be covered in scars, or they have burr holes in their skull. The effects of operation may, of course, lead to subsequent genuine surgical emergencies. Such patients often discharge themselves against medical advice and then go on to another hospital under another name.
- Self-mutilators are often immature young people with unstable backgrounds and multiple social problems. They may make multiple and especially longitundinal cuts on forearms or elsewhere under stress. Others will swallow pins, cutlery or insert needles under the skin, produce puzzling blisters with cigarettes, or haematuria by urethral trauma. They may require emergency surgical care.
The emergency management of all the above patients is difficult. Kindly confrontation with the recognition that they are needing psychological or social help, if one is reasonably sure of the diagnosis, may be profitable but they rarely stay long enough to benefit from any help offered. In all such cases well-kept notes can be invaluable if they ever return to the hospital. A photograph of the patient may be useful in identifying someone who changes names, as may a photograph (or good drawing) of a suspected self-inflicted skin lesion.
The post natal patient
Psychiatric disorders of the puerperium are not fundamentally different from illnesses occurring at other periods in a woman's life. However, the added dimension of a baby requiring care and close contact with its mother will complicate management. A post-natal neurosis or psychosis may become manifest days, or even months, after delivery.
Post-natal neurotic reaction:
A young mother who has had her first child may become overwhelmed with the responsibility of looking after a helpless baby. She may be immature and poorly supported by her husband, often badly housed and perhaps from a different culture, without the traditional supports of an extended family. She may present in a panic with her baby, complaining that it is not thriving, (even if it is) or have fears of harming it. Such fears may be entirely groundless, but the danger of non-accidental injury may be present, especially if she is complaining of irritability and insomnia.
Puerperal depressive psychosis - a woman with ideas of hopelessness, guilt and loss of feeling for her baby should be asked tactfully about suicidal ideas and ideas that the child might be better off dead. In such cases there may be a risk of infanticide.
Puerperal psychosis - the classical syndrome of delusions, hallucinations and emotional incongruity may be present and the mother may show complete indifference towards her baby.
- The husband / partner should be involved in all decisions if at all possible
- A social worker and psychiatrist should be alerted at the outset
- Every effort should be made to keep mother and child together under close supervision ( including during their stay in the Emergency Department)
- Admission to a Mother & Baby Unit may be difficult as an emergency
- Consider temporary re-admission to an Obstetric Unit
- A grossly psychotic mother may need admission alone and arrangements made for the care of the baby by relatives, social services or admission to a Paediatric Ward.
The demented patient
Patients suffering from chronic brain syndromes may be brought to hospital by relatives, neighbours, the Gardaí or social workers because of increasing confusion and anti-social behaviour, such as aggressive outbursts, noisiness, leaving gas taps on and the like, when a social crisis point has been reached and the patient can no longer be tolerated by those around him. A history should be obtained as quickly as possible from those who have brought the patient - they may disappear once the patient has reached the hospital.
Common causes of increased confusion are:
- prescribed drugs or alcohol
- head injury
- infections, especially chest, UTI
- malnutrition(vit defic)
Increased confusion may also occur when an old person is transferred from one environment to another, e.g.. from home to an Old People's Home. Admission to appropriate medical care may be indicated if a disorder is found, but more often the cause of the crisis is a social one and the limit of tolerance has been reached by neighbours or relatives. If, for example, the patient lives with a daughter then the latter will need to be given a sympathetic hearing and reassurance that all possible social services will be mobilised and she may be persuaded to continue caring for her aged parent. However, the point of no return may have been reached when the old person has become such a burden that the relative can no longer cope and may be in danger of being physically aggressive towards the patient ("granny beating").
Crisis admission will be necessary, but finding suitable accommodation in either a local authority home or psychiatric unit may be extremely difficult and time consuming. The EM doctor will need to use all his or her powers of persuasion and tact.
The confused patient
"Confusion" is often mis-applied to mean bewilderment, poor concentration or incoherence
It should only be used when a degree of clouding of consciousness or disturbed awareness (which may be fluctuating) is present. Although confusion may occur in patients suffering from manic excitement - and it may also resemble schizophrenia - it should be assumed that such a clinical presentation is due to organic disease or trauma.
The clinical picture will vary from clouding of consciousness to delirium.
Clouding of consciousness
Difficulty in maintaining attention, distractibility, illusions (e.g. seeing faces on the wall), irritability, noise intolerance, emotional lability, suspiciousness and fleeting paranoid ideas.
Disorientation in time and place, dream-like hallucinations (often visual), poor comprehension, impaired memory, restlessness, plucking movements and fearfulness. The cause will be (a) cerebral, or (b) extra-cerebral. (More on delirium).
- post epileptic
- all psychotropic drugs
- anti-Parkinsonian drugs (including L-dopa)
- anoxia, hypoglycaemia, hypothyroidism
- vitamin deficiencies (especially thiamine and B12)
- electrolyte disturbances, hepatic failure and uraemia
- infections - chest, urinary tract
- drug and alcohol withdrawal
- constipation and urinary retention
The majority of patients suffering from confusional states will require urgent admission to a medical ward.
The panic stricken patient
Acute anxiety, associated with a fear of imminent loss of control, dissolution, serious disease or death, may occur as a symptom of
- Organic disease
- Drug intoxication or withdrawal
- Schizophrenia or
- Agitated depression
Most commonly it will be a manifestation of phobic anxiety with hyperventilation.
Organic disease - serious disease of sudden onset may cause understandable secondary anxiety and fear of death, such as myocardial infarction, spontaneous pneumothorax and asthma. In addition, panic may be an integral part of the symptomatology of temporal lobe epilepsy, which may be associated with a feeling of epigastric "butterflies" rising up to the neck. Other symptoms, such as olfactory hallucinations or deja vu experiences may be elicited. Superventricular paroxysmal tachycardia associated with a sudden onset of palpitations may present as panic.
Drugs - amphetamines and cocaine can produce panic because of their sympathomimetic effect. Hallucinogonic drugs (often in first-time users) such as cannabis and LSD may give rise to a "bad trip" with subsequent panic. Withdrawal from benzodiazepines, barbiturates and alcohol can cause anxiety attacks.
Psychiatric disorders - acute schizophrenic illnesses in young people may present with panic as they become aware of hallucinations, delusions and inability to control their thoughts, while the older patient suffering from an agitated depression may have episodes of intense anxiety. Attacks of panic can occur for some patients in specific situations. Agoraphobia is perhaps the most common, when a patient will have a panic attack in crowded places such as shops or cinemas. Even if he or she has had repeated similar attacks it is no more reassuring for him or her to know that they usually pass. He or she will be in a state of high arousal, tense, restless, with cold extremities and tachycardia. He or she will be hyperventilating, perhaps to the point of carpopedal spasm.
Anxiety can be very infectious so it is vital to maintain a calm approach and encourage and reassure those around the patient. Obviously organic disorders must be excluded as rapidly as possible and dealt with on their merits.
Drug withdrawal syndromes must be identified by careful enquiry. Tension, panic and irritability may precede a seizure, so in addition to calm reassurances 5 - 10 mg of Diazepam by mouth may be necessary as an emergency measure. Admission for withdrawal under diazepam (CIWA-Ar) cover may be indicated (alcohol section).
Psychosis as a cause of panic is relatively rare. A brief discussion will usually reveal some of the typical symptoms of schizophrenia or agitated depression. A phenothiazine, e.g. thioridazine 50 - 100 mg orally, will be the appropriate treatment and admission may have to be considered.
The acute panic reaction associated with phobic situations usually subsides rapidly when away from the triggering cause. However, some patients will come to hospital in a panic state suffering from the effects of hyperventilation, with light-headedness, air hunger and palpitations. Firm reassurance and explanation that they are breathing unnecessarily fast and deeply may be sufficient to relieve them. Re-breathing into an anaesthetic mask or a paper bag (not plastic) should rapidly restore the pH to normal and relieve the symptoms. It is helpful to anticipate the fears of such patients and give specific reassurance that they are not going mad, about to die or have a heart attack. Unfortunately, continued over-breathing can cause frightening carpopedal spasm or sometimes a fit in susceptible subjects which will serve to reinforce anxiety. Drugs are rarely necessary and should be avoided if possible. However, if panic does not respond to a psychological approach coupled with re-breathing, an oral dose of Diazepam 5 - 10 mg can be given.
The psychiatrically disturbed child
Acutely psychiatrically disturbed children are a relatively rarity in Emergency Departments. The successful management of such patients will call for careful assessment of the child and the involvement of parents and others, such as GP's, social workers and teachers, who may have had previous contact with the child. Behaviour leading to the child being brought to hospital will usually be:
- Sself-harm, e.g. overdose, self-mutilation, drug experimentation.
- Uncontrollable or violent behaviour.
Disturbed behaviour in young people is usually due to problems within the family or school. However, early onset affective disorders or schizophrenia can occur.
- Drug experimentation
- Head injury
- Other organic disorders can present as loss of control.
Establish who is responsible for the child - parents, guardian, local authority care, etc., and involve them in any decisions.
- Obtain as much history as possible from the child and those who have brought him/her to the hospital.
- Contact the GP and social services, if appropriate.
- Children who have taken overdoses or harmed themselves will require admission to a medical or paediatric ward. Disturbed or unmanageable behaviour will often respond to a calm, neutral, reassuring approach but (a) physical treatment, (b) drugs, may occasionally be necessary.
- If possible the permission of both parents should be obtained before this is resorted to.
- In a crisis the wishes of the parents or guardian must take precedence over the wishes of the child.
- All such emergencies refer to senior staff in Child Psychiatry or, if not available, a Consultant in Adult Psychiatry.
Adverse reactions to psychotropic drugs
(Phenothiazines, e.g.. chlorpromazine; butyrophenones, e.g.. haloperidol; or long-acting injectable anti-psychotic drugs, e.g.. fluphenazine or flupenthixol). Patients receiving treatment with these drugs may present as acute emergencies due to extra-pyramidal reactions.
- Oculogyric Crisis:- (more on dystonic reaction). This frightening complication can be of sudden onset (perhaps after failing to take anti-Parkinsonian drugs) and terrify the patient, his friends and even the doctor. His back may arch, eyes become fixed upwards and jaws clenched. It may be mistaken for the tonic spasm of an epileptic seizure, tetanus or acute torticollis or, more commonly, as "hysterical" behaviour. I.V.procyclidine 5 - 10 mg will usually relieve the symptoms rapidly.
- Acute Akathisia:- This is a less severe reaction than an oculogyric crisis, characterised by intense restlessness. It may be mistaken for acute anxiety or agitation, but unlike anxiety it is completely unresponsive to reassurance or attempts at voluntary control and there is usually a degree of muscular rigidity of extra pyramidal type. IV procyclidine 5 - 10 mg will usually relieve the condition, but it may be necessary to give i.v. Diazepam 5 mg in addition.
Monoamine oxidase inhibitors (Tranylcypromine, phenelzine).
An acute hypertensive crisis (the cheese reaction) may occur if the patient has eaten a food containing tyramine or taken a sympatho-mimetic drug (e.g. cold cure capsule). The patient will complain of an intense occipital headache reminiscent of a subarachnoid haemorrhage (the acute rise of blood pressure may even produce intracranial bleeding) and palpitations.
Long-term management of many depressive illnesses. Toxic reaction if dehydrated by heat or diuretics, or if overdose of the drug causing the serum level to rise above 1.5 mmol per litre.
- Ataxia, confusion, muscle twitching
- Vomiting and lethargy
- Seizures and coma.
Admit immediately for electrolyte replacement ± renal dialysis.
These patients normally complain of severe abdominal colic, chest pain, renal colic as well as other illnesses. Refer to the appropriate file or circular which gives names and information about known "hoppers". Inform the EM Duty doctor.