Psychiatric Seminar Series
Dr. Roger HoAssistant ProfessorDepartment of Psychological MedicineNational University of Singapore
Emergency Psychiatric MedicineOut 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 CaseA 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 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 objectivesAssess the current risk of self harm and suicide.Assess the psychosocial backgrounds, stressors and coping resourcesHighlight the risk of physical complications if the overdosing continuesIdentify psychiatric disorder, including depression, substance misuser and personality traits. Discharge against doctors 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 overdoseIntention at the time of overdose and at presentIntention to avoid discoveryHow 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 depression.Elaborate plan made to end life and plans to stop being found out.Isolation, living alone, severe psychosocial difficultiesAlcohol, substance, drug misuseAccess to lethal items or weaponsPoor impulse and anger control
What are your differential diagnosis?
DDXAcute stress reaction.Adjustment disorder with brief depressive reactionMild depressive episodeRecurrent depressive disorderBorderline personality disorderSubstance abuse
Under what circumstances would you consider to admit the patient?
If she continues to present a high risk of suicide or self harm and no regretful feelingIf she suffers from moderate to severe depressionIf 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 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 CallEnsure 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 1bA 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.
Whats wrong with the consultants decision?
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?
Primary objectivesShow 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 staffDecide whether to allow the patient to stay or transfer to IMH.
AssessmentPatient: 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?
Intoxicated with drugs (secretly taking in the ward),Delirium tremens due to alcohol withdrawalWithdrawal of other substances like opioidParanoid schizophrenia with substance abuseManic episode with high irritability Antisocial personality trait Interpersonal conflicts
How would you de-escalate the situation?
De-escalationTalk to the patient first; de-escalate by verbal techniquesIf 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 statApply 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 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 callAttach 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 3aA 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?
Acute and transient psychosisSchizophreniaBipolar affective disorder manic phaseSevere depressive episode with psychotic featuresSubstance induced psychotic disorderPsychotic disorder related to other medication such as steroidEndocrine disorderTemporal 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