A basic overview for emergency department nurses on managing mental health presentations.

2. Learning Points
 Overview of MH in ED
 Basic Mental Health Assessment
 Managing common disorders

3. Psych Resources in ED
 24/7 Duty PLN & Psych Registrar
 24/7 Oncall Psych Consultant
 Social worker
 Drug & Alcohol nurse
 SHACCS

4. ED’s Role
 Stabilise aroused/frightened patient
 Manage acute behavioural disturbances
 Excluded medical causes
 Determine need for voluntary vs involuntary
 Arranging referral/disposition
 Family/carer support

5. Brief Assessment
 Circumstances of referral /Presenting problem
 Social circumstances
 Previous treatment /Current mental health service
 ETOH & drug use
 Mental state exam
 Medical/Risk assessment & investigations
 Provisional Dx
 Treatment & disposition

6. Medically Clearance
 Contentious issue
 “Fit for psychiatric evaluation”
 High risk:
 First time presenters
 Failure to take Hx
 Poor attention vital signs/ physical Ax

7. Screening for Medical Cause
 Vital signs:
Consider (case specific)
 FBC, U&E, TFT
 Paracetamol level
 ECG
 Urinalysis
 +/- Head CT/MRI
 +/- LP

8. Medical causes of Psychosis
 Epilepsy
 Hypo/hyper thyroidism
 Huntington’s disease
 Porphyria
 B12 deficiency
 Cerebral neoplasm
 Stroke
 Viral encephalitis
 AIDS
 Neurosyphillis

9. Medical causes Depressive
symptoms
 Hyperthyroidism
 Hypercalcaemia
 Pernicious anaemia
 Pancreatic Ca
 Lung ca
 Dementia

10. Drug Abuse = Psychosis
 Amphetamines
 Cocaine
 PCP
 LSD
Withdrawal:
 Alcohol
 Benzo’s

11. Mental State Exam

12. Mental State Exam
 Appearance & Behaviour
 Speech
 Mood & Affect
 Form of thought
 Content of thought
 Perception
 Sensorium & Cognition
 Insight

13. Appearance & Behaviour
Appearance:
 Grooming, posture, clothing, build
Behaviour:
 Eye contact, cooperativeness
 Motor activity
 Abnormality of movement
 Expressive gestures

14. Speech
 Articulation disturbances
 Rate
 Volume
 Quantity of information:
 Pressured
 Loud
 Slurred
 Mumbled

15. Mood & Affect
Mood:
 Depressed, euphoric, suspiciousness
Affect:
 Restricted, flattened, inappropriate

16. Form of Thought
 Amount of thought
 Rate of production
 Flight of ideas
 Derailment
 Continuity of ideas
 Disturbance in language & meaning

17. Content of Thought
 Suicidal/ homicidal thoughts
 Delusions
 A belief held with strong conviction despite evidence
to the contrary.
 Overvalued ideas, obsessions, phobias

18. Perception
 Hallucinations
 A perception in the absence of apparent stimulus that
has qualities of real perception.
 Other perceptual disturbances:
 Derealisation
 Depersonalisation
 Illusions

19. Sensorium & Cognition
 Level of consciousness
Memory:
 Immediate, recent, remote
Orientation:
 Time, place, person

20. Insight
 Capacity to understand:
 Own symptoms/illness
 Knowledge of medications
 Amenable to treatment
 Likelihood of compliance treatment

21. Documentation
NAB HECTOR
• Name
• Age
• Build
 Height
 Eyes
 Complexion
 Thatch (hair)
 Oddities (scars, tattoos,
deformities)
 Rig (clothing)

22. Suicide
 Patients often prevent suicidal
 Overdose
 Self harm
 Plan
 ED role
 Risk assessment
 Prevent suicide
 Offer support/disposition

23. Why do people self harm?
 Significant proportion intend to die
 Escape intolerable situation
 No clear explanation “Loosing control”
 Punish someone “makes others feel guilty”
 Excess of life events
 Bereavement
 Job loss
 Financial difficulties

24. Risk Factors for Suicide
 Being single, divorced, widowed
 Unemployed
 Recent life stresses
 Having mental illness
 Previous self harm
 Substance abuse problem

25. Duty of Care
 Duty of care needs to be enacted when:
 Risk to self (suicidal)
 Risk to others (homicidal)
 Under command auditory hallucinations
 Lack insight/capacity

26. The Big 5 Disorders
 Depression
 Anxiety
 Bipolar Disorder
 Psychosis/Schizophrenia
 Borderline personality disorder

27. Case 1
 55 male
 Wife left him
 Lost Job
 Increasing ETOH consumption
 BIBP after calling mate saying was going to hang
himself

28. Depression
Can be:
 Acute major depressive
 Chronic (dysthymia)
 Affects 3-5% worlds population
 “Serotonin depletion”

29. Characteristics
Physical symptoms:
 Fatigue
 Nausea
 Headaches

30. ED Management
 Kindness and reassurance
 Ensure patient safety (contain till risk Ax)
 Explore suicidal ideation
 Psych disposition (Admit vs O/P follow up)
 Antidepressant may be started in ED
 SSRI or SNRI

31. Case 2
 19 female
 Presents with palpitations/nausea
 Hyperventilating “I'm going to die”
Social Hx:
 Doing uni exams
 Found out BF kissed another girl

32. Anxiety
 More difficult emotion to handle:
 Compared to anger/depression
 Cascade of symptoms often overwhelming
 Strong component of other psychiatric illness’s

33. Panic/Anxiety Attacks
 Overwhelming sense fear/doom
 Uncooperative/Irrational
 Often unable to process what is being said to them

34. Characterised
Physical:
 Nausea
 Chest pain
 Shortness of breath
 Dizziness
 Headache

35. ED Management
 Explore/rule out physical symptoms
 Listen & reassure
 Arrange follow up
 Benzo’s have limited role
 Antidepressants may help
 Coping techniques

36. Case 3
 47 male
 Presents rambling
 Trashed house after loosing 5k at casino
 Hx of depression
 States all is find then goes of on tangents

37. Bipolar Disorder
 aka- Manic depressive illness
 Disruption in brain chemistry
 Major mood swings

38. Characteristics
 Extreme mood swings/behaviours
 Mania severe depression
Mania
 Grandiose
 Delusional thinking
 Rapid pressured speech
 Impulsive risk behaviours

39. ED Management
 Low stimulus
 Keep directions/statements short simple
 Medicate for agitation
 Assume unpredictable
 Often will require admission during acute episode
 Lithium/Carbamazepine long term

40. Case 4
 22 male
 Presents paranoid
 Aliens & space ships are following him”
 Refusing to engage at triage
 ?hx of amphetamine use

41. Psychosis
Characterised by:
 Delusional
 Hallucinations
 Disorganisation of thinking

42. Psychosis vs
Schizophrenia
Psychosis:
 Short term
 Drug induced or medical induced
Schizophrenia:
 Disruption in brain chemistry
 Onset typically adolescents/young adults

43. ED Management
 Ensure safety
 Don’t feed into delusions
 Ask about voices/visual hallucinations
 Provide low stimulus environment
 Medicate for agitation

44. Case 5
 26 female
 Presents with DSH to foramen/ paracetamol OD
 5th presentation in 5 weeks
 Hx of PTSD- child abuse
 Refuse's to cooperate
 Abusing staff – you don’t understand

45. Borderline Personality
Disorder
 Rigid fixed perception – world
 Often in pts with traumatic childhoods
 Extreme fear abandonment

46. Characteristics
 Chaotic relationships
 Intense reactions to situations
 Dramatic-manipulative behaviours
 Attention seeking behaviour
 Self harm – manage intense feelings
 Often chronically suicidal

47. ED Management
 Avoid power struggles
 Avoid punitive treatments, ultimatums
 Often require short period containment
 Medicate as appropriate to control behaviour
 Prepare for high risk behaviour (Self, others)

48. Questions

49. Take Home Points
 Know the resources available
 These patients can be confronting
 Learn an approach
 Most are not violent
 Always ensure safety first yourself then your patient

50. Thank You