Psychological Care in Trauma Patients

1. Psychological Care in Trauma Patients ??:970804 ???:???

2. Introduction Causes of psychological problems Symptoms of ICU psychosis Psychological reactions Assessment Interventions to prevent psychological problems Management of PTSD/ASD Specific patient groups Families of trauma patients Conclusions Content of Topics

3. Introduction What is ICU psychosis? ICU psychosis is ICU syndrome. ICU psychosis is also a form of delirium, or acute brain failure. How long does ICU psychosis last? it may last 24 hours or even up to two weeks with fluctuations of the level of consciousness and behavior patterns. experience anxiety, become paranoid, hear voices, see things that are not there, become severely disoriented in time and place, become very agitated, even violent, etc.experience anxiety, become paranoid, hear voices, see things that are not there, become severely disoriented in time and place, become very agitated, even violent, etc.

4. Causes of psychological problems Sudden and unexpected nature of events Pain ICU environment Other factors .The loss of control over their lives that patients often feel in an ICU. The incident ,ambulance journey,admission procedures,surgical or transfer to ICU Disruption of the normal day-night rhythmThe incident ,ambulance journey,admission procedures,surgical or transfer to ICU Disruption of the normal day-night rhythm

5. What causes ICU psychosis? Environmental Causes Sensory deprivation (being put in a room often without windows, away from family, friends and all that is familiar) Sensory overload (being tethered to noisy machines day and night) Sleep disturbance and deprivation Continuous light levels Stress Lack of orientation Medical monitoring Environmental Causes Sensory deprivation: A patient being put in a room that often has no windows, and is away from family, friends, and all that is familiar and comforting. Sleep disturbance and deprivation: The constant disturbance and noise with the hospital staff coming at all hours to check vital signs, give medications, etc. Continuous light levels: Continuous disruption of the normal biorhythms with lights on continually (no reference to day or  night). Stress: Patients in an ICU frequently feel the almost total loss of control over their life. Lack of orientation: A patient's loss of time and date. Medical monitoring: The continuous monitoring of the patient's vital signs, and the noise monitoring devices produce can be disturbing and create sensory overload. Environmental Causes Sensory deprivation: A patient being put in a room that often has no windows, and is away from family, friends, and all that is familiar and comforting. Sleep disturbance and deprivation: The constant disturbance and noise with the hospital staff coming at all hours to check vital signs, give medications, etc. Continuous light levels: Continuous disruption of the normal biorhythms with lights on continually (no reference to day or  night). Stress: Patients in an ICU frequently feel the almost total loss of control over their life. Lack of orientation: A patient's loss of time and date. Medical monitoring: The continuous monitoring of the patient's vital signs, and the noise monitoring devices produce can be disturbing and create sensory overload.

6. What causes ICU psychosis? Medical Causes Pain (which may not be adequately controlled in an ICU) Critical illness: The pathophysiology of the disease, illness or traumatic event - the stress on the body during an illness can cause a variety of symptoms. Medication (drug) reaction or side effects: Infection creating fever and toxins in the body. Metabolic disturbances: electrolyte imbalance, hypoxia (low blood oxygen levels), and elevated liver enzymes. Heart failure (inadequate cardiac output) Cumulative analgesia (the inability to feel pain while still conscious) Dehydration Medical Causes Pain which may not be adequately controlled in an ICU Critical illness: The pathophysiology of the disease, illness or traumatic event - the stress on the body during an illness can cause a variety of symptoms. Medication (drug) reaction or side effects: The administration of medications typically given to the patient in the hospital setting that they have not taken before. Infection creating fever and toxins in the body. Metabolic disturbances: electrolyte imbalance, hypoxia (low blood oxygen levels), and elevated liver enzymes. Heart failure (inadequate cardiac output) Cumulative analgesia (the inability to feel pain while still conscious) Dehydration Medical Causes Pain which may not be adequately controlled in an ICU Critical illness: The pathophysiology of the disease, illness or traumatic event - the stress on the body during an illness can cause a variety of symptoms. Medication (drug) reaction or side effects: The administration of medications typically given to the patient in the hospital setting that they have not taken before. Infection creating fever and toxins in the body. Metabolic disturbances: electrolyte imbalance, hypoxia (low blood oxygen levels), and elevated liver enzymes. Heart failure (inadequate cardiac output) Cumulative analgesia (the inability to feel pain while still conscious) Dehydration

7. Symptoms of ICU psychosis extreme excitement anxiety restlessness hearing voices clouding of consciousness hallucinations nightmares paranoia disorientation agitation delusions abnormal behavior fluctuating level of consciousness which include aggressive or passive behavior.

8. Specific problems threatening traumatised patient Helplessness Humiliation Body image Mental symptoms

9. Psychological reactions Conservation withdrawal Denial Regression Anger Anxiety Depression Grief (Denial,bargaining,anger,depression and acceptance ) Management of defence mechanisms Conservation withdrawal:psycho-stimulants,antidepressants,or psychological intervention Denial: AngerManagement of defence mechanisms Conservation withdrawal:psycho-stimulants,antidepressants,or psychological intervention Denial: Anger

10. Assessment Impact of event scale (IES) a self-report 15-item scale Clinician administered PTSD scale (CAPS) 30-item structured interview Brief symptom inventory (BSI) Structured clinical Interview for DSM-IV disorders (SCID-IV) Post-traumatic diagnostic scale (PTDS) Davidson trauma scale (DTS) Mississippi scale for post-traumatic stress disorder(MISS) How is ICU diagnosed? stroke low blood sugar drug or alcohol withdrawal, and any other medical condition that may require treatment. How is ICU diagnosed? stroke low blood sugar drug or alcohol withdrawal, and any other medical condition that may require treatment.

11. Can ICU psychosis be prevented? using more liberal visiting policies providing periods for sleep protecting the patient from unnecessary excitement minimizing shift changes in the nursing staff caring for a patient, orienting the patient to the date and time reviewing all medical procedures with an explanation about what to expect asking the patient if there are any questions or concerns talking with the family to obtain information regarding religious and cultural beliefs, and even coordinating the lighting with the normal day-night cycle, etc.

12. Interventions to prevent psychological problems Pain control?analgesic drugs Liberal reassurance Family support Day-awake,night-asleep Removing many wires and tubes Constant and monotonus sounds like that of an air conditioner should be minimished. Large clock,calendar and and outside window visible to the patients to help with orientation. Personally familiar beside objects such as clock,radio or family photographs. Use spectacles or hearing aids. Such as radio or television sets to provide meaningful sensory stimuli The atmosphere created by staff members can be made more supportive. Repeated explanations or instructions may become necessary due to deficit in recent memory. Medical discussions should be avoided. Social support to overcome their financial problems.

13. Management of PTSD/ASD Psychotherapy Cognitive-behavioural therapy(CBT) ,includes ‘exposure procedures’ , ‘cognitive restructuring procedures’ , ‘Anxiety Management programs’ Pharmacotherapy Tricyclic antidepressants and MAO inhibitors Selective serotonin reuptake inhibitors (SSRIs) and serotonin antagonist and reuptake inhibitors(SARIs)

14. Specific patient groups Head injured patients rehabilitation starts within first 6 months Patients with spinal cord injury kinetic therapy , regarding sexual relations and functioning should be dealt with honestly. Patients with amputated limbs Psycho-therapeutic interventions , vocational retraining

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16. Death and dying It becomes a demanding task on the part of the treating clinician to support a patient who is confounded by the fear of being alone and in pain.

17. Families of trauma patients Intervention strategies Two-way commumication Honest information Regular meetings with family Message board can be provided outside ICU or trauma ward Written information Waiting area should be well-lit and comfortable with windows,telephone,coffee and vending machines

18. Conclusions It is the responsibility of the treating personnel to comprehend the psychological effects of trauma in patients and their families, and to take necessary steps to prevent and treat these through knowledge, skill and understanding.