Transcript How would you manage this case? Management

Psychiatric Seminar Series
Psychiatric Emergencies
Dr. Roger Ho
Assistant Professor
Department of Psychological Medicine
National University of Singapore
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.
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?
• 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.
What the features that suggest a
medical cause of a mental
disorder?
• Acute onset (within hours or minutes, with prevailing
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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.
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?
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.
What additional information would
you seek to assess the severity of
this episode of suicide attempt?
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
What are the factors which
increase the suicide risk?
• Definite intent to end her life.
• Frequent self harm or suicide behaviour.
• Past or current history of moderate to severe
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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
What are your differential
diagnosis?
DDX
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Acute stress reaction.
Adjustment disorder with brief depressive reaction
Mild depressive episode
Recurrent depressive disorder
Borderline personality disorder
Substance abuse
Under what circumstances would
you consider to admit the patient?
• If she continues to present a high risk of suicide or
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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.
What would you do if her suicide
risk is deemed to be high and
refuse to be transferred to IMH?
• Persuade the patient to be admitted.
• Inform her that you need to send her to IMH for assessment
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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.
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?
Case 2
You 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?
Primary objectives
• Show appreciation of the need for urgency due to
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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.
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.
What are your DDX?
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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
How would you de-escalate the
situation?
De-escalation
• Talk to the patient first; de-escalate by verbal
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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
What would be your short term
management if the patient suffers
from 1) delirium tremens 2)
Paranoid schizophrenia?
• 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.
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?
• This is usually indicated by forensic history, challenging
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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.
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?
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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
• 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?
Case 3
A 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.
DDX
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Neuroleptic Malignant Syndrome
Serotonin Syndrome (more rapid, less rigid)
Catatonia
Acute lethal catatonia
CNS infection
Toxaemia due to overdose or poisoning
Drug withdrawal
What are the other signs you would
look for in Neuroleptic Malignant
Syndrome?
Other signs in NMS
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Dysphagia
Tremor
Incontinence
Altered level of consciousness, ranging from
confusion to coma and mutism
• Labile blood pressure
• Leucocytosis in FBC
How would you manage this
case?
Management
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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.
9. External cooling treatment
After the patient has recovered
from NMS, what medication would
you give to the patient?
Medication
1. Avoid haloperidol
2. Avoid first generation antipsychotics.
3. Consider second generation antipsychotic such as
risperidone, olanzapine or quetiapine.
4. If NMS has not fully recovered and patient is very
psychotic, consider ECT.
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.
Brief summary of common emergency
scenarios (1)
• Alcohol intoxication: observed in AED
• Alcohol withdrawals: admit to medical, start thiamine 30mg
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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.
Brief summary of common emergency
scenarios (2)
• Confused elderly: FBC, RFT, LFT, TFT, urine FEME,
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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