Transcript Psychiatric Emergencies

Psychiatric Emergencies
Dr R Jacob
Consultant Psychiatrist
Fulbourn Hospital
Cambridge
Case Vignette 1
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A 70 yr old man presents to the ED and is admitted
to the medical ward with a working diagnosis of
pyelonephritis. On the evening of his admission he
becomes irritable, confused and expresses concerns
that the nurses are poisoning him. During the course
of the evening he hits out at the nurse who comes to
examine him.
How will you manage this case?
Delirium
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A transient, organic mental syndrome
characterised by confusion, impaired
consciousness, disorientation, and psychotic
phenomena including paranoid delusions and
visual hallucination
Most common cause of disturbed/aggressive
behaviour on medical wards.
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Acute onset, fluctuating severity and often
worse at night.
Assess cognitive functions: attention,
orientation and memory important
Causes of Delirium
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Drug intoxication-anti-cholinergics
Drug Withdrawal
Infection
Metabolic causes
CNS disorders- head injury, epilepsy
meningities, raised intracranial pressure
Immediate management of
the violent patient
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Quickly assess available information
Request suitably trained back-up staff
Clear immediate vicinity, give patient space,
Remove potential weapons, ensure escape
Offer sedation- CAUTION
Restraint with rapid tranquillisation if
imminent violence suspected.
Management of delirium
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General and supportive measures- side room,
adequately illuminated environment
Specific treatment of underlying cause.
Pharmacological management- low dose
haloperidol/ atypicals increasingly used.
In delirium caused by withdrawal,
benzodiazepines helpful.
Case Vignette 2
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A 40 year old man present to the ED with a minor
injury to his face, following a RTA. He is admitted to
the plastic surgery ward for further management. All
other investigations including a CT scan have been
normal.
The next morning he is tremulous, nauseated and
soon after complains of frightening visual images,
such as insects crawling up his leg.
What are your differential diagnoses and how will
you manage this case?
Alcohol Withdrawal
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Symptoms of withdrawal 8-24 hours after last drink,
including tremors, sweating, flushing, disorientation,
vomiting, seizures……may progress to Delirium
Tremens.
Beware concomitant infection, dehydration
DT’s mortality rate has been recorded as high as 1520% in the past.
Management of Alcohol
Withdrawal
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Benzodiazepines : Chlordiazepoxide 120mg in
a reducing regimen over 9 days.
DT’s can treat with diazemuls slow IV (rate of
5mg/minute).
Vitamin replacement specifically Thiamine
should be given parenterally 2 amp daily x 3
days.
Case Vignette 3
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A patient well known to psychiatric services
with a diagnosis of paranoid schizophrenia is
admitted with a relapse of his symptoms. He
becomes aggressive psychotic and you
decide to treat with IM Haloperidol 5mg.
He suddenly appears rigid and has torticollis
and appears to be going into an oculogyric
crisis.
How do you manage this emergency?
Acute Behavioural Disturbance
and Acute Dystonias
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Adverse effect of high potency neuroleptics
such as haloperidol.
Responds to anti-cholinergic medication: give
IM Procyclidine 5mg stat and prn.
Avoid further neuroleptics till you can
prescribe Midazolam/Promethazine IM if
patient still disturbed.
Case Vignette 4
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A 35 year old lady with a diagnosis of
Bipolar Affective Disorder, admitted to
the ward, displays symptoms of ataxia,
vomiting and a course tremor.
What might be the cause and how will
you investigate and manage this
patient?
Lithium Toxicity
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Symptoms usually occur at a serum-lithium level over
1.5mmol/litre. The patient may present with
confusion and ataxia associated with diarrhoea,
vomiting, drowsiness, and a coarse tremor.
If symptoms are mild do urgent U&E’s and lithium
levels. If levels are high (over 1.2mmol/litre) then the
lithium should be stopped and further management
discussed with the responsible psychiatrist.
If the patient is unwell and lithium toxicity is
suspected IV hydration and symptomatic treatment
will be required.
Case Vignette 5
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A 19 yr old lady is admitted to the CDU
following and overdose of paracetamol.
Following appropriate blood tests, she is
deemed to require the anti-dote parvolax.
Unfortunately she become aggressive with
ward staff and announces her intention to
immediately leave hospital.
How do you manage this case?
Basic Legal Proposition
(most democratic countries)
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Health treatment may involve ‘battery’ or ‘assault’
without consent.
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Consent requires that a person is adequately
informed and has the capacity to make the decision
for him/herself.
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All adults are presumed to have decision-making
capacity to consent or refuse treatment.
Mental Capacity Act
2005
MCA 2005 Principles
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Principle 1: ‘a person must be assumed to have
capacity unless it is established that he lacks
capacity.’ (section1(2))
Principle 2: ‘ a person is not to be treated as
unable to make a decision unless all practicable
steps to help him to do so have been taken
without success.’ (section1(3))
Principle 3: ‘a person is not to be treated as
unable to make a decision merely because he
makes an unwise decision.’ (section 1(4))
MCA 2005 Principles
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Principle 1: ‘a person must be assumed to have
capacity unless it is established that he lacks
capacity.’ (section1(2))
Principle 2: ‘ a person is not to be treated as
unable to make a decision unless all practicable
steps to help him to do so have been taken
without success.’ (section1(3))
Principle 3: ‘a person is not to be treated as
unable to make a decision merely because he
makes an unwise decision.’ (section 1(4))
MCA 2005 Principles
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Principle 4: ‘An act done, or decision made,
under this Act for or on behalf of a person
who lacks capacity must be done, or made, in
his best interests.’ (section 1(5))
Principle 5: ‘Before the act is done, or the
decision is made, regard must be had to
whether the purpose for which it is needed
can be as effectively achieved in a way that is
less restrictive of the persons rights and
freedom of action.’ (section 1(6))
Definition of Incapacity
‘A person lacks capacity in relation to a
matter if at the material time he is unable to
make a decision for himself in relation to the
matter because of an impairment of, or a
disturbance in the functioning of, the brain or
mind’
Section 2(1) Mental Capacity Act 2005
Inability to make decisions
A person is unable to make a decision for himself if he
is unable(a) to understand the information relevant to the
decision,
(b) to retain that information,
(c) to use or weigh that information as part of the
process of making the decision, or
(d) to communicate his decision (whether by talking,
using sign language or any other means).
S3 (1) Mental Capacity Act 2005
Algorithm for Refusal of Treatment
NICE Self-Harm 2004
Does the patient have capacity to refuse?
Yes- ReB
No
Mental disorder?
Yes
Rx for mental disorder
using MHA’83
No
Physical illness
Best Interest Principles
Best Interest Principles
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Risks and benefits of different options
(‘life, health and well-being’)
Previously expressed wishes
Present ascertainable wishes
Views of family and/or significant others
Least restrictive/invasive option
Mental Capacity Act 2005
How do we manage Competent
Treatment Refusal?
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Have we ensured there is no
ambivalence or fluctuation in decisionmaking?
Have we attempted to encourage and
enhance compliance?
Have we considered the use of Mental
Health Act ’83?
Have we sought legal advice?
Clinical ‘bottom line’
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Even those patients who have capacity to
refuse treatment must be encouraged and
advised to seek treatment.
Seek second opinion and legal advice if in
any doubt.
‘Better to be sued for assault by a living
patient, than for negligence by bereaved,
grieving relatives’.
Legal/Clinical Divide
The general law on mental capacity is, in my
judgment, clear and easily to be understood
by lawyers. Its application to individual cases
in the context of a general practitioners
surgery, a hospital ward and especially in an
intensive case unit is infinitely more difficult
to achieve’
Dame Butler Sloss, 2004