Psychiatric Emergencies

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.

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
Delusions
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.
Insight

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?

DSH

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 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 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:

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.

Delirium

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).

The majority of patients suffering from confusional states will require urgent admission to a medical ward.

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:

1. Sself-harm, e.g. overdose, self-mutilation, drug experimentation
2. 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.

• Epilepsy
• Drug experimentation
• Head injury
• Other organic disorders can present as loss of control

Management:

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

Hospital Hoppers

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.

Links

• Delirium
• Alcohol problems
• Mental Health Act
• Involuntary admission from ED
• Dystonic reaction