Emergency Room Psychiatry

1. Emergency Room Psychiatry Professor Moruf Adelekan Consultant Psychiatrist Royal Blackburn Hospital Blackburn United Kingdom

2. The interview: Some possible constraints • Time limitation • Sense of urgency to assess the risk • Lack of collateral information • Patient’s distress • Patient’s long and rambling accounts of their problems • Pressure from carers • A&E or ward targets/limitations

3. The interview • Psychiatrist’s relationship with the patient influences the interview. • Back to basics: • Techniques of questioning • Observation • Interpretation • Being straight forward, honest, calm and non-threatening helps. • Ability to convey to the patient that you are in control and will act indecisively to protect them and others. • Communicate clearly your impression and management plan.

4. The setting • Safety: Be very conscious of your safety and that of other staff (How?) • Sitting arrangement: how far from patient, at what level and angle? • The room: door, alarm system • Interview style and approach: • calm manner • quiet voice • avoid eye contact, if this will aggravate patient • sit rather than stand • Avoid the attitudes and behaviours that increase patient anxiety and frustration

5. General Strategy • Self protection • Know as much as possible about patient. • Be alert for aggression. • Attend to safety of physical surroundings. • Have others present during the interview if needed. • Have others in vicinity. • Attend to developing alliance with the patient.( do not threaten or confront patients with paranoia)

6. General Strategy (contd.) • Prevent harm • Prevent self harm or suicide. Use whatever safe methods to prevent them from harming themselves. • Prevent violence towards others. Consider the following: • Inform patient that violence is not acceptable. • Approach patient in nonthreatening manner. • Reassure. • Offer medication. • Inform patient that restraint is used if necessary. • When patients are restrained observe their vitals closely. • Administer immediate treatment for agitation

7. History, MSE, PE and Investigations • What are the key areas to check in the history? • What about MSE? • General PE • PE where cerebral pathology is suspected • Level of consciousness: from fully awake, to drowsiness, stupor, semi-comatose, deep coma • Clouding of consciousness, delirium and fugue • Language ability etc. • Investigations: Bloods; Illicit drug screen, ECG, Brain scan

8. The pitfalls • The physical health problems • Head trauma • Seizures • Metabolic abnormalities • Infections etc. • Substance use/misuse disorders • Acute intoxication • Withdrawals • Delirium • Wernicke’s encephalopathy etc. • Medication related • Intoxication • Withdrawals • Allergic reactions • Overdoses etc.

9. DELIBERATE SELF HARM: EPIDEMIOLOGY • 1% of patients who deliberately self-harm commit suicide in the first year. • Of DSH patients, 10% ultimately commit suicide • 50% of completed suicides have a history of DSH

10. DSH: ASSESSMENT • Interview informants, family and friends • The following point to intention: • Planned • Precautions taken to being found • Was help sought • Had the patient considered that he or she had taken sufficient to kill self or be dangerous • Suicide note • Active hostility aimed at another • Present intention: • Still present? • Precipitant to DSH

11. Factors that increase risk • History of harm (to self/others) • Pre-existing vulnerabilities: Male, Young, Disrupted or Abusive Childhood, Antisocial, Suspicious, Impulsive, Irritable • Social and Interpersonal factors: Poor social network, Lack of education, Lack of work skills, Rootless, Poverty, Homelessness • Mental disorders (mania, schizophrenia, depression, psychopathic disorders etc) particularly characterised by: • active symptoms • poor compliance • poor engagement with services • treatment resistance • lack of insight • Substance Misuse (past but more importantly current)

12. Factors that increase risk (contd.) • Mental state • thoughts of self harm or violence • paranoid thoughts • command hallucinations • mood disturbance • delusions evoking fear, provoking indignation, provoking jealousy, involving injury/threat from close relative or companion • ideas of influence • clouding consciousness and confusion • Situational triggers • Availability of weapons • Loss • Demands and expectations • Confrontation • Change • Physical illness • Other provocation

13. Specific poisoning • Check what to do with the following: • Benzodiazepine • Carbon Monoxide • Cyanide • Opiates • Paracetamol • SSRIs • Lithium

14. Violence and assaultative behaviour • Ascertain cause. • Look for predictors: • Recent acts • Verbal/physical threats • Carrying weapons/objects • Progressive agitation • Catatonic excitation • Substance intoxication • Impulse dyscontrol etc. • Assess the risk for violence • Consider past history • Overt stressors • Consider intention, wish, availability of means etc..

15. General principles of management of violence • Ensure sufficient staff are present. Request support from security personnel, if indicated. Disarm weapons • Verbal talk-down, e.g. for half an hour – may not work if psychotic or organic • Physical restraint/seclusion, e.g. for drug free evaluation • Treat psychiatric illnesses appropriately • Medication as emergency: • Neuroleptic antipsychotics in sedative doses • Choice depends on the protocol used in treatment unit • Caution: possible brain damage as increased side effect; akathisia which may be misdiagnosed as agitation • Benzodiazepines • Can be combined with neuroleptics e.g. lorazepam/clonazepam + haloperidol • Risk of confusion and disinhibition of violence, especially at high doses and in brain damage • Staff debriefing following serious untoward incident

16. Rapid tranquilization (RT) • The use of psychotropic medication to control agitated, threatening or destructive psychotic behaviour. • This procedure can be used in the Emergency Unit as well as Inpatient Unit. • However, staff have to be adequately trained and the procedures should be meticulously implemented to ensure good results and safety of everyone (the patient, staff and other patients) • An example of the Policy Guide from Lancashire care NHS Trust is available for a full study of what the RT entails

17. ACUTE PSYCHOSIS • Severe mental illness • Disorder of thinking and perception • Loss of contact with reality • Lack of insight • Patient usually frightened of his or her experiences, thus limiting engagement with mental health professionals

18. ACUTE PSYCHOSIS: SIGNS AND SYMPTOMS • POSITIVE SYMPTOMS: delusions, hallucinations, formal thought disorder • NEGATIVE SYMPTOMS: flat affect, poverty of thought, lack of motivation, social withdrawal • COGNITIVE SYMPTOMS: distractability, impaired working memory, impaired executive function • MOOD SYMPTOMS: depression, elevation • ANXIETY/PANIC/PERPLEXITY • AGGRESSION/HOSTILITY/SUICIDAL BEHAVIOUR

19. ACUTE PSYCHOSIS:AETIOLOGY • PRIMARY FUNCTIONAL PSYCHOTIC DISORDERS • SCHIZOPHRENIA • BIPOLAR DISORDER • DEPRESSION • SCHIZOPHRENIFORM DISORDER • SCHIZOAFFECTIVE DISORDER • DELUSIONAL DISORDER • ACUTE AND TRANSIENT PSYCHOTIC DISORDERS • SECONDARY (ORGANIC) PSYCHOTIC DISORDERS • DEMENTIA • ACUTE CONFUSIONAL STATE • PSYCHOSIS RESULTING FROM AN ORGNIC (PHYSICAL) DISORDER • ALCOHOL-INDUCED • DRUG INDUCED

20. ACUTE PSYCHOSIS:INVESTIGATIONS • Detailed History and MSE • Blood tests and full blood count • Urea and Electrolytes • Random blood sugar • Liver, kidney and thyroid function tests • Urine drug screen • Pregnancy test • ECG • EEG • Brain imaging (CT or where available MRI scan)

21. ACUTE PSYCHOSIS:MANAGEMENT • Assess danger for self and others • Consider disposal options (admission, immediate treatment followed by community follow-up etc. • Antipsychotic medication (several options): note principles of usage • Treat anxiety, agitation and insomnia with short-term diazepam. CPZ and Quetiapine can also be used • For mania, prescribe a mood stabiliser • If depressed, consider use of adjunctive antidepressant • Consider long-acting depots where compliance or poor response from oral meds is an issue • Psychological intervention, social intervention, rehabilitation etc.

22. Anxiety • Anxiety could be a manifestation of most major psychiatric conditions • Other causes include: • Substance misuse disorders – alcohol and drug withdrawal • Intoxication: Drugs (e.g. penicillin); Caffeine; Poisons (e.g. Arsenic, Hg) • Intracranial: Brain tumours, Head injury, CVD, Subarachnoid haemorrhage, Encephalitis • Endocrine: Pituitary, Thyroid, Parathyroid, Adrenal Dysfunctions; Phaeochromocytoma, Hypoglycaemia • Hyperventilation: hyperpnoea or tachypnoea with palpitations, dizziness, tinnitus, chest pain, paraesthesia • Impending myocardial infarction • Hypoglycaemia • Cardiac arrhythmias • Pulmonary embolism • Post ictal etc.

23. Management of acute anxiety • Aim at treating the underlying cause • Explain the nature of the symptoms to the patient, e.g. palpitations and chest pain because of fear of heart attack • Reassure the patient • Breathing exercises can be given: make use of of a paper bag into which the patient can rebreathe to help reduce the resp. alkalosis that worsen the condition • Relaxation techniques – these may involve progressive muscular relaxation • Patient should be encouraged to keep a diary of daily activities and progress made. Longer term psychological treatment • Benzodiazepines: rapid anxiolytic effect; start low dose; avoid long-term use and dependency; rebound withdrawal symptoms

24. Suspecting medical cause for any presentation? • Acute onset • First episode • Geriatric age • Current medical illnesses/injury • Substance misuse, Overdoses • Non auditory disturbances of perception • Neurological signs: • Loss of consciousness seizures, change in pattern of headache, head injury etc. • Mental status signs: • Diminished alertness, disorientation, impaired attention etc.

25. Acute organic brain syndrome/Ac. Confusional states/delirium • Up to 1 in 10 admissions to general medical wards, and up to one-third in those over 65 • Associated with increased morbidity and mortality rates, and increased length of stay in hospital • Clinical presentation • An acute onset • A fluctuating course • Inattention • Wandering thoughts • A fluctuating level of consciousness • Hallucinations, particularly visual, illusions and nightmares • Drowsy or agitated or restless • Clinical picture usually worse at night • Short-term memory impairment • Lability of mood • Fear and apprehension • Disturbed or apparently “strange” behaviour

26. Acute OBS: Aetiology • Causes are organic and theoretically reversible, although could be superimposed on chronic organic mental disorders • Common causes: • Infection: Cerebral malaria, UTI, HIV • Metabolic disturbance: causes include hypoxia, electrolyte imbalance, and respiratory, cardiac and renal failure • Endocrine disorders: diabetes mellitus, including insulin-induced hypoglycaemia; Cushing’s syndrome • Vitamin deficiencies: Thiamine in alcoholics and vit B12 in pernicious anaemia • Neurological: head injury, ictal or post-ictal states in epilepsy, space occupying lesions, raised intracranial pressure, cerebrovascular disease • Drugs: Psychotropics (may be used to treat AOBS but may exacerbate them); Benzodiazepines (intoxication or withdrawal); antipsychotic medication; antidepressants; Cardiac meds such as digoxin or diuretics; Antiparkinsonian drugs such as L-dopa; Corticosteroids; Opiates for analgesia • Alcohol withdrawal: delirium tremens • Postoperative: including from the effects of general anaesthesia

27. Acute OBS: Principles of Management • Identification and treatment of underlying cause • Attention to nursing and environment: Keep surroundings well lit and continuously orientating the patient to time and place; introduce new staff; give explanations and reassurance about procedures • Drug treatment: • Sedative medication can clearly aggravate an ACS and may exacerbate underlying medical conditions such as hypoxia through sedation • However, haloperidol, when judiciously used, can control an otherwise unmanageable or aggressive behaviour • Be aware of drug interactions: for example prescribed psychotropic drugs and drugs prescribed for underlying medical and surgical conditions; and the effects of liver disease on drug metabolism

28. Immediate medical treatment • Common global neurological disorders: • Wernicke’s encephalopathy – confusion, ataxia and opthalmoplegia - Thiamine 100 mg i.v immediately • Opioid intoxication – pin point pupils not responding • naloxone 4 mg i.v • Hypoglycemia – i.v Dextrose or Glucagon • Delirium Tremens (Latin for shaking frenzy) • Develop 2-3 days after cessation of heavy drinking. Life threatening. • Down regulation of GABA and up regulation of excitatory neuro transmitters like noradrenaline, dopamine etc.. • Adrenergic storm-hypertension, tachycardia, hyperreflexia, diaphoresis, hyperthermia, anxiety, paranoia and panic attacks and neurotoxicity. • Primarily visual hallucinations but could be tactile – Formication. • Associated with metabolic disturbances and seizures. • Symptomatic Rx and Benzo regimen e.g. Valium/Librium. • Treat Seizures symptomatically. • Never volunteer to treat on Psychiatric ward.

29. Extra pyramidal side effects • Acute dystonic reactions • Torticollis, oculogyric crisis, spasms of back, tongue or jaw. • Painful and frightening. • More common in young males, neuroleptic naïve and high potent first generation antipsychotics. • Occurs within hours of taking oral and minutes of i.m. • Anticholinergics (Procyclidine), antiparkisonian drugs (Trihexyphenidyl) or muscle relaxants (diazepam) • i.m or oral depends on severity of symptoms. • Remember patient might not be able to swallow. • Akathisia • Unpleasant sensations of "inner" restlessness that manifests itself with an inability to sit still or remain motionless. • Foot stamping when seated, constant crossing/uncrossing legs, rocking and constantly pacing up and down. • Anticholinergics (Procyclidine) and Propranolol.

30. Extra pyramidal side effects • Parkinsonian SEs • Muscular lead-pipe rigidity, bradykinesia/akinesia, resting tremor, bradyphrenia, salivation and postural instability. • Occur days to weeks after antipsychotic drug Rx • Consider other neurological conditions. • Anticholinergics might play a role in relief of symptoms. • Tardive dyskinesia • Long-term extrapyramidal SEs of antipsychotic use • Prevalence of 15-25%, and starts months or years after commencing antipsychotic use • Non-drug related cases in the elderly reported • Risk factors: female sex, affective disorder, organic brain disease, parkinsonian side effects during acute treatment, alcohol abuse, negative symptoms of schizophrenia and increasing age • Symptoms: Lip smacking or chewing, tongue protrusion, choreifrom hand movements(pill rolling) or pelvic thrusting. Severe orofacial movements-difficulty speaking, eating or breathing. • Management: Difficult. Dose reduction; Benzodiazepines (e.g. Clonazepam)and muscle relaxants, tetrabenazine (a dopamine-depleting agent), vitamin E (a free radical scavenger) and lithium. Weak evidence base for all the strategies. • In severe cases, switch to clozapine. • Use minimum effective dose of drugs, preferably where possible, oral form.

31. Neuroleptic malignant syndrome • Medical emergency, life-threatening and requires immediate treatment • Occurs most often with drugs which act directly on central dopaminergic systems (haloperidol, CPZ) but has also been reported with other drugs such as antidepressants (e.g. Dothiepin) • Likely an idiosyncratic reaction; some patients have been cautiously re-challenged on same drug without recurrence • Marked and sudden reduction in dopamine activity: • Withdrawal of dopaminergic agents • Blocking dopamine receptors • 05-1% of patients on neuroleptics will develop NMS, with most developing it shortly after initial exposure (90% within 2 weeks) • Clinical features • Autonomic dysfunction (hyperthermia, labile BP, pallor, sweating, tachycardia) • Fluctuating level of consciousness (stupor) • Muscular rigidity • Urinary incontinence • Investigations: Blood tests may show raised serum creatine kinase, leucocytosis • Management • Clinical emergency • Stop offending antipsychotic drug immediately • Admit patient to a medical ward where maximal supportive care is available • Sometimes, Dantrolene or Bromocryptine (a dopamine agonist Haloperidol and Chlorpromazine are greatest risk.