Psychiatric Seminar Series Psychiatric Emergencies

1. Psychiatric Seminar SeriesPsychiatric Emergencies Dr. Roger Ho Assistant Professor Department of Psychological Medicine National University of Singapore

2. Emergency Psychiatric Medicine • Out of the 5 general hospitals, only NUH has stay-in psychiatric medical officer on call. • If you works in the AEDs in other general hospitals, you are required to perform emergency psychiatric assessment and decide whether to consult psychiatrist-on-call or not. • You are often limited by time constraints in the busy AED. You need to have a structured interview, obtain core information from patient and informants and make a reasonable estimation of the psychiatric and medical risks.

3. Illustrated Case • A 20-year-old lady was brought in by her friend after she was fainted. The AED doctor called the psychiatrist-on-call to assess the patient. She was noted to be disorientated, could not recall what has happened or her current occupation. She was noted to be drowsy and disorganised in her behaviours. She also passed urine on the floor. Her mother reported that she had no psychiatric history. The AED MO discovered that she was seen by polyclinic for management of depression. • What is your DDX and how would you manage this case if you were the AED MO?

4. The greatest potential error in emergency room psychiatry is overlooking a: physical illness as the cause of an emotional illness. • Head traumas, medical illnesses, substance abuse (including alcohol), cerebrovascular diseases, metabolic abnormalities, and medications may all cause abnormal behaviour.

5. What the features that suggest a medical cause of a mental disorder?

6. Acute onset (within hours or minutes, with prevailing symptoms) • First episode • Geriatric age • Current medical illness or injury • Significant substance abuse • Non-auditory disturbances of perception • Neurological symptoms-loss of consciousness, seizures, head injury, change in headache pattern, change in vision. • Classic mental status signs-diminished alertness, disorientation, memory impairment, impairment in concentration and attention, dyscalculia, concreteness • Constructional apraxia-difficulties in drawing clock; cube, double intersecting pentagons.

7. Case 1a A 24 – year – old woman with no previous psychiatric history was seen at accident and emergency department after taking an overdose of 20 tablets of paracetamol. This followed an argument with her 23 – year – old boyfriend. She is medically fit and wants to be discharged. What would you do assume your hospital does not have a psychiatrist on call?

8. Primary objectives • Assess the current risk of self harm and suicide. • Assess the psychosocial backgrounds, stressors and coping resources • Highlight the risk of physical complications if the overdosing continues • Identify psychiatric disorder, including depression, substance misuser and personality traits. • Discharge against doctor’s advice and discharge under the care of family/ Transfer patient to Institute of Mental Health. • Contingency management: What should the patient do if she has suicidal thought again.

9. What additional information would you seek to assess the severity of this episode of suicide attempt?

10. What additional information would you seek on this episode of suicide attempt? • Preparation for this episode of suicide attempt. • Circumstances surrounding the overdose • Intention at the time of overdose and at present • Intention to avoid discovery • How and why did the patient seek medical help after the overdose? • Current risk of suicide: does the patient still have intention to die?. • Obtain collateral history

11. What are the factors which increase the suicide risk?

12. Definite intent to end her life. • Frequent self harm or suicide behaviour. • Past or current history of moderate to severe depression. • Elaborate plan made to end life and plans to stop being found out. • Isolation, living alone, severe psychosocial difficulties • Alcohol, substance, drug misuse • Access to lethal items or weapons • Poor impulse and anger control

13. What are your differential diagnosis?

14. DDX • Acute stress reaction. • Adjustment disorder with brief depressive reaction • Mild depressive episode • Recurrent depressive disorder • Borderline personality disorder • Substance abuse

15. Under what circumstances would you consider to admit the patient?

16. If she continues to present a high risk of suicide or self harm and no regretful feeling • If she suffers from moderate to severe depression • If she is unable to guarantee her safety. • She is in a severe situational crisis. • Her family members strongly recommend admission.

17. What would you do if her suicide risk is deemed to be high and refuse to be transferred to IMH?

18. Persuade the patient to be admitted. • Inform her that you need to send her to IMH for assessment and potential admission under the Mental Health Act (Most of the patients would agree to be admitted to a general hospital at this stage) • Call 6389 2000/ 6389 2003 to speak Registrar on Call • Ensure the necessary investigations are done before transferral (IMH does not have a lab after 5pm) • Ensure she is medically fit before transferral. • Send the patient to IMH by an ambulance with a memo. • Patient can only be discharged from your hospital if family signs an AOR. • Not discharge under any circumstances if patient tries to jump, stab himself or herself, tried to gas himself or herself or has become a police case.

19. Case 1b A 30-year-old man tried to attempt suicide by drinking unknown solution. He was drowsy and did not say much in the AED. In view of a number of cases recently committed suicide in the hospital by jumping, the AED consultant insisted that this case must be admitted to the psychiatric ward as he does not want to see another patient committed suicide in this hospital appears on the newspaper. What’s wrong with the consultant’s decision?

21. Case 2You are the medical HO on call. You have been called by your nurse that a 36-year-old man admitted to the ward due to withdrawal with history of polysubstance abuse has attacked a female nurse, biting her on the face. How would you manage this case if you have no psychiatrist on call in your hospital?

22. Primary objectives • Show appreciation of the need for urgency due to risk and safety issues. • Consider DDX along the line of substance abuse. • Formulate immediate and short term management. • Ensure safety of staff • Decide whether to allow the patient to stay or transfer to IMH.

23. Assessment • Patient: reason for admission, withdrawal of what substances (opioid or alcohol), current mental state (look for hallucination, delusion, insight, affect), current laboratory results and medications. • Staff: circumstances leading to the incident, recent behaviours in the ward • Senior nursing staff: his or her view to keep the patient in the ward.

24. What are your DDX?

25. Intoxicated with drugs (secretly taking in the ward), • Delirium tremens due to alcohol withdrawal • Withdrawal of other substances like opioid • Paranoid schizophrenia with substance abuse • Manic episode with high irritability • Antisocial personality trait • Interpersonal conflicts

26. How would you de-escalate the situation?

27. De-escalation • Talk to the patient first; de-escalate by verbal techniques • If fail, consider oral medication: Lorazepam 1mg stat or Haloperidol 5mg stat or Diazepam 5mg stat. • If fail, consider intrumuscular injection: Lorazepam 2mg stat or Haloperidol 5mg stat • Apply physical restraint if patient is not cooperative. • You can repeat IM Haloperidol 5mg if not sedated. • Monitor blood pressure and pulse rate hourly. • Make sure you have access to resuscitation equipments

28. What would be your short term management if the patient suffers from 1) delirium tremens 2) Paranoid schizophrenia?

29. For delirium tremens/alcohol withdrawal, please ensure there is an adequate coverage with benzodiazepine: Diazepam 5mg TDS, +/- antipsychotics: Haloperidol 5mg BD to TDS. Make sure the patient is on Thiamine 30mg OM to prevent development of Werknicke encephalopathy or Korsakoff psychosis. • For Paranoid schizophrenia, increase the dose of current antipsychotics, add Lorazepam 0.5mg to 1mg TDS. • Continue to apply physical restraint.

30. What would you do if the patient seems to have antisocial personality trait and the senior nurse feels unsafe to keep patient in the ward?

31. This is usually indicated by forensic history, challenging behaviour, absence of psychotic features. • Ensure there is no outstanding medical issue. • Inform the family on your decision to transfer patient to IMH and for admission. • D/W IMH registrar on call • Attach a memo and indicates current medical management and follow – up plan. • Sedative prior transferral: IM lorazepam 2mg stat or Haloperidol 5mg stat if not settled with oral medication. • Transfer by ambulance.

32. Case 3a • A 20-year-old staff nurse at IMH was brought to the AED of a general hospital due to acute changes in behaviour. He told his family that he heard voices and felt his colleagues wanted to harm him. He has been absent from work for the past 3 days. He was previously seen by IMH psychiatrist for anger management. • What is your DDX? • How would you manage this patient?

33. Acute and transient psychosis • Schizophrenia • Bipolar affective disorder – manic phase • Severe depressive episode with psychotic features • Substance induced psychotic disorder • Psychotic disorder related to other medication such as steroid • Endocrine disorder • Temporal lobe epilepsy

34. He came with a staff nurse friend. His friend disagreed with his family for bringing in the patient to be assessed in a government hospital. He strongly feels that there will be a breach of confidentiality and has persuaded the family to bring patient home. • How would you manage this situation?

35. Case 3A 50 – year – old lady who has been maintained on Haloperidol for the last 2 years was readmitted a week ago. She presented with symptoms of depression and was started on citalopram in a 20mg dose. Your house officer has contacted you, stating that the patient has been feeling unwell for last few days. Creatinine kinase (CK) level is 1500 units/L. She is now acutely ill and semiconscious. What are your DDX and management approach.

36. DDX • Neuroleptic Malignant Syndrome • Serotonin Syndrome (more rapid, less rigid) • Catatonia • Acute lethal catatonia • CNS infection • Toxaemia due to overdose or poisoning • Drug withdrawal

37. What are the other signs you would look for in Neuroleptic Malignant Syndrome?

38. Other signs in NMS • Dysphagia • Tremor • Incontinence • Altered level of consciousness, ranging from confusion to coma and mutism • Labile blood pressure • Leucocytosis in FBC

39. How would you manage this case?

40. Management • Further laboratory testing: to rule out infection, toxicology. • Discontinue antipsychotics and antidepressants. • Consult medical • May need to be transferred to medical ICU. • Rehydration • Support ventilation and stabilise autonomic function • Diazepam 5mg TDS to relax muscles and reduce agitation. • Treat with a direct-acting dopamine agonist such as bromocriptine. • External cooling treatment

41. After the patient has recovered from NMS, what medication would you give to the patient?

42. Medication • Avoid haloperidol • Avoid first generation antipsychotics. • Consider second generation antipsychotic such as risperidone, olanzapine or quetiapine. • If NMS has not fully recovered and patient is very psychotic, consider ECT.

43. Case 4 A 60-year-old American male presents to the AED. He was noted to have change in behaviour for the past one month. He is becoming more impulsive and decides to sell all his stock. He is suspicious of his wife and does not trust her to handle his financial affairs. He has appointed a financial advisor from the US to help him. His wife does not notice that he has significant memory impairment. His mood is labile and judgement is poor. What is your DDX?If you only have 3 minutes, can you perform one test to illustrate the sign of your primary diagnosis.

44. Brief summary of common emergency scenarios (1) • Alcohol intoxication: observed in AED • Alcohol withdrawals: admit to medical, start thiamine 30mg OM, diazepam 5mg TDS; if delirium tremens, add in Haloperidol 1.5-3mg TDS • Drug induced psychosis: Haloperidol 1.5 – 3mg TDS • Anorexia Nervosa: must be admitted to the medical/paediatric ward. Slow in re-feeding after admission • Acute psychosis: Haloperidol 1.5mg – 3mg BD/ Risperidone 1mg BD • Psychosis in elderly: Quetiapine 25mg – 50mg BD. • Catatonia: IM lorazepam 2mg stat, Lorazepam 0.5mg BD and stop current antipsychotics • Acute dystonia: IM congentin 2mg stat and brief observation for response.

45. Brief summary of common emergency scenarios (2) • Confused elderly: FBC, RFT, LFT, TFT, urine FEME, CXR. Start Haloperidol 1.5mg BD or quetiapine 25mg BD • Acute Mania: Olanzapine 5mg BD • L-dopa induced psychosis in Parkinson disease: Quetiapine 25mg BD • Alleged sexual assault: inform police, consult O/G • Panic disorder: deep relaxation exercise, propanolol for palpitation (with no history of asthma); paper bag is no longer used due to CO2 retention • Insomnia: sleep hygiene, hydroxyzine 25mg ON, lorazepam 0.5 – 1mg ON