Chapter 55. Psychiatric emergencies
Mentally ill patients may be admitted to hospital involuntarily under the Mental Health Act if they are deemed to be a risk to themselves or to others, however most do not need this level of intervention.
• Nature and onset of presenting symptoms
• Past psychiatric history
• Past medical history
• Current medication
• History of substance misuse
• Social support.
Physical examination
• A brief physical examination should be carried out in every case, as far as possible, even if there appears to be no apparent physical disorder
• Common organic causes of psychiatric emergencies include hypoglycaemia, infection, cardiac failure, delirium tremens and subdural haematoma
• Recreational drug use and alcohol misuse are commonly implicated.
Mental state examination
This includes:
• Appearance and behaviour
• Speech form (i.e. coherence) and content
• Beliefs and thoughts
• Overall mood state and whether it is congruent with the thought content
• Observable abnormal perceptions or experiences (e.g. hallucinations)
• Assessment of level of consciousness, orientation to time, place and person, concentration and short-term memory
• Presence of insight (the acknowledgement by the patient that there are psychological problems that need to be resolved)
• Suicidal ideation.
Psychosis: recognition and treatment
Psychosis refers to disturbances in thinking and behaviour, usually involving delusions, hallucinations and thought disorder. They may be attributable to a diagnosis such as schizophrenia, mania or psychotic depression.
Delusions
• A delusion is a firmly held but false belief that is out of context with the person’s social and cultural background
• Paranoid delusions may be that they are being persecuted or hounded by others or that others are watching or listening to them through bugging devices.
Hallucinations
• Hallucinations refer to the experience of perceptions (e.g. hearing voices or noises, seeing vivid images or tasting particular flavours) in the absence of a stimulus causing the perception. They appear real to the patient.
Dangerous behaviour
• Occasionally, psychiatric patients have a tendency to be violent, usually as a direct consequence of their illness
• Clearly it is inadvisable to enter a situation that puts the paramedic in physical danger and if there is a likelihood that this will occur, the police should be involved
• It is inadvisable to assess an acutely psychotic patient alone because of the risk of unpredictable behaviour that may lead to injury.
Always have an escape route
Management of psychosis
Controlling a patient’s behaviour can often be achieved by use of good interpersonal skills of empathy, reassurance, a non-threatening posture and an air of calmness and confidence.
Antipsychotic drugs
Antipsychotic drugs have an initial sedative action that precedes any antipsychotic effect. They need to be prescribed and administered by a doctor.
Parasuicide: recognition and treatment
• The first consideration must be safeguarding the physical welfare of the patient and this will usually entail transportation to the Emergency Department
• Do not be deceived by any apparent evidence that only a small quantity of tablets have been ingested or the patient’s protestations that the overdose was not life-threatening
• Patients are often unaware of the lack of toxicity of the medication that they have taken and believe that the quantity ingested was sufficient to cause death
• More violent methods of attempted self-harm (e.g. hanging, shooting or deep lacerations) should always be assessed by a psychiatrist
• Attempted suicide should be considered as a possibility at any single-occupant road traffic collision where the conditions of the accident are unclear
• Self-harm is not in itself a mental illness and the majority of people who harm themselves have no psychiatric illness
• If the person agrees to admission to hospital and this is appropriate, then it should be expedited. If the person does not agree, but is detainable under the Mental Health Act, then the appropriate procedures should be followed with the patient being closely supervised until admission takes place
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