Caroline Delaforce and Brian Dolan

Chapter Contents

Introduction

It is estimated that 1–2 % of clients presenting to an Emergency Department (ED) require a formal mental-state assessment (Andrew-Starkey 2004). At any one time, common mental health disorders, including depression and anxiety disorders, can be found in around one in six people in the community. Of these, around half have significant symptoms that would warrant intervention from healthcare professionals (National Institute for Health and Clinical Excellence 2011).

The prevalence of individual common mental health disorders varies considerably. The 1-week prevalence rates from the Office of National Statistics 2007 national survey (McManus et al. 2007) were 4.4 % for generalized anxiety disorder, 3.0 % for post-traumatic stress disorder (PTSD), 2.3 % for depression, 1.4 % for phobias, 1.1 % for obsessive-compulsive disorder (OCD), and 1.1 % for panic disorder. Estimates of the proportion of people who are likely to experience specific disorders during their lifetime are from 4–10 % for major depression, 2.5–5 % for dysthymia, 5.7 % for generalized anxiety disorder, 1.4 % for panic disorder, 12.5 % for specific phobias, 12.1 % for social anxiety disorder, 1.6 % for OCD and 6.8 % for PTSD.

More than half of people aged 16 to 64 years who meet the diagnostic criteria for at least one common mental health disorder experience co-morbid anxiety and depressive disorders (National Institute for Health and Clinical Excellence 2011). This does not include major psychiatric disturbances such as schizophrenia, which has a prevalence of approximately 1 % of the population. A psychiatric emergency is any disturbance in the client’s thoughts, feelings or actions for which immediate therapeutic intervention is necessary.

EDs play a critical role in the assessment and management of people presenting with mental health disorders (Nicholls et al. 2011). People who come to the ED range from those with specific requests for help to those who are brought in against their will for reasons they do not understand. In either case, the client or carers may believe that the client is no longer able to maintain coping abilities at his usual level of functioning.

The reasons why many of these clients attend ED are multifactorial. A primary reason, however, is the deinstitutionalization of the mentally ill, due to the introduction of psychotropic medication in the 1950s and the changing focus on treatment, rehabilitation and least restrictive practices within the community. As a consequence, for many in society, their only access to healthcare is through ED.

For the ED nurse who deals with various life-threatening emergencies on a routine basis, these needs may not appear to be true emergencies; however, it is a crisis that brings the mental health client to the ED and the nature and degree of a crisis are defined by the person experiencing it. It is also to be seen as an opportunity, because prompt and skilful interventions may prevent the development of serious long-term disability and allow new coping patterns to develop (Richards 2001, Guidelines and Audit Implementation Network 2010).

Aetiology of mental illness

It is recognized that genetic, biological and biochemical dyscrasias play a significant role in the causes of major psychiatric illness. It is therefore difficult to discuss psychiatric disorders as having a purely organic or functional basis. However, for the purpose of this chapter organic disorders will be considered as those disorders that have a grossly identifiable and potentially reversible physiological cause, such as endocrine and metabolic disorders, neurological causes and drug-induced states. Functional disorders will be considered as those disorders without a grossly identifiable physiological cause.

Assessment of mental health clients

The goals of ED psychiatric evaluation are to conduct a rapid assessment, including diagnosis of any underlying medical problems, to provide emergency treatment and to arrange appropriate disposition. These goals will be hampered by various obstructions and restrictions, such as time and space, departmental milieu, inability to obtain a history from a disturbed or distressed client and experience of staff. Information collected must be concise and methods of assessment flexible enough to take into consideration the client’s and the unit’s needs. Relevant details must be documented accurately, as they may be the only recorded evidence of symptoms displayed by the client in the acute phase. This forms the baseline for the management and treatment plan. Records are also important for medico-legal reasons. The nurse should make full use of any collateral information available, such as family, escorts, ambulance personnel, community staff, police, hospital notes and other staff who may know the client from previous attendances or admissions. Once an assessment is made, the client should be given the appropriate triage category employed by the unit, e.g., Manchester Triage guidelines (Mackway-Jones et al. 2005).

Acute organic reactions

Frequently, acute organic reactions present to the ED as psychiatric emergencies when the aetiology is unknown and there is loss of behavioural control (Box 15.1). The most consistent symptom of an acute organic reaction is impairment in the consciousness, worsening symptoms at night, and good pre-morbid personality.

Acute psychotic episode

Psychotic clients experience impaired reality testing as they are unable to distinguish between what is real and what is not. Their thought processes are often disordered and often characterized by hallucinations, delusions, ideas of reference, thought broadcasting and thought insertion (Kaiser & Pyngolil 1995) (Box 15.3). It is essential that the ED nurse is able to differentiate between a psychosis with an organic cause, e.g., delirium, and a functional psychosis, e.g., schizophrenia. Psychotic clients may present to the ED on an emergency basis when it is:

Anxiety states

Anxiety is an emotional sense of impending doom, a mental sense of unknown terror or fear of losing one’s mind (Kaiser & Pyngolil 1995). The client may present to the ED when symptoms are no longer tolerable or when there is a marked deterioration in ability to carry out day-to-day activities. Clients may also present with panic attacks.

Alcohol-related emergencies

Around 90 % of the adult population drink alcohol at some time, 28 % of men and 11 % of women exceed safe levels of consumption, 1–2% of the population have alcohol problems and there are 200 000 dependent drinkers in the UK. Every year, the adverse effects of alcohol consumption lead to an estimated 1.2 million assaults, result in 150 000 hospital admissions and costs the NHS ≤1.7 billion (Smith & Allen 2004, Bellis et al. 2005, Fuller et al. 2009, National Collaborating Centre for Mental Health 2011).

Alcoholic clients may present with a variety of problems:

It is dangerous and unrealistic to attempt to conduct a satisfactory psychiatric interview when someone is intoxicated. While this may occasionally leave ED staff feeling frustrated, on-call psychiatrists or community psychiatric nurses (CPNs) will rarely attend ED while the client is intoxicated on the grounds that no meaningful psychiatric interview can take place. Clinical management of clients with alcohol intoxication is often confounded by the potentially disruptive and violent behaviour associated with intoxication.

Alcohol is a central nervous system (CNS) depressant. Measures of alcohol are described in units, with one unit being equal to half a pint of ordinary beer, one standard glass of wine or one-sixth of a gill of spirit (a pub measure) at 40 % alcohol concentration. Blood alcohol concentration (BAC) is a measure of the amount of alcohol (mg) present in the bloodstream (per 100 mL), with a standard unit containing approximately 15 mg of alcohol. As with any drug, the effect of a certain dose will vary with the physical and psychological condition of the user (Kennedy & Faugier 1989). Degrees of intoxication may be classified as mild, moderate or severe.

Mild intoxication occurs in individuals with a BAC of up to 80 and is usually achieved with between one and five units. The typical reaction in an emotionally stable person is a feeling of warmth and cheerfulness accompanied by impairment of both judgement and inhibition. Apart from an increased susceptibility to accidents and the risk of post-intoxication headache and mild gastritis there is negligible health risk from a single episode of intoxication at these levels.

Moderate intoxication occurs in individuals with a BAC of between 80 and 150, who will exhibit a loss of self-control, slurred speech, double vision and memory loss. This is usually achieved with doses of up to 10 units. These symptoms are similar to those of raised intracranial pressure, diabetic hypoglycaemia and drug overdose. These and other possible aetiologies must therefore be excluded prior to such behaviour being ascribed purely to alcohol intoxication.

Accurate assessment and diagnosis of a client’s condition at this level of intoxication may be confounded due to alcohol’s desensitizing effect on pain response and its disruption to levels of consciousness. Other health problems from this level of intoxication include vomiting, severe gastritis, pancreatitis, hepatitis and interactions with medication and/or existing medical problems (Taylor & Ryrie 1996).

A BAC of between 200 and 400 leads to sleepiness, oblivion and coma, with possible cough reflex depression and airway obstruction from vomit or tongue. Such clients require constant neurological observation and may well require airway and cardiovascular support.

With a BAC of more than 400, death from severe CNS depression, particularly respiratory depression, is possible. Full emergency resuscitation with endotracheal intubation and cardiovascular support may be necessary. Stomach lavage should be considered with extreme caution since chronic alcohol abuse may result in peptic ulceration and/or oesophageal varices. In very severe alcohol poisoning, some clients may require transfer to intensive care units for haemodialysis or haemoperfusion. A BAC of over 600 is usually fatal and is generally only achieved by ingestion of large amounts of spirits.

Munchausen’s syndrome and Munchausen’s syndrome by proxy

This is characterized by a client frequently and repeatedly seeking admission, usually travelling to out-of-area ED units. Munchausen’s syndrome and Munchausen’s syndrome by proxy are characterized by a person simulating physical or mental illness, either in himself or, in the case of Munchausen’s by proxy, in a third person, e.g., a child. The carer, usually the mother or both parents, fabricates symptoms or signs and then presents the child to hospital. There is an overlap with other forms of child abuse (see also Chapter 17).

The symptoms are supported by a plausible history and convincing physical signs. Motivation derives from a desire for attention. Physical examination may reveal multiple scars. Walsh (1996) identified five broad types of presentation by clients with Munchausen’s syndrome:

Suicide and deliberate self-harm

Suicide occurs when a person knowingly brings about his own death. There are approximately 4000 suicides in England and Wales each year, equivalent to one death every two hours, and it is the third most common cause of death in people aged 15–30 years. In England the death rate from suicide is 8.6 deaths per 100 000 population. The majority of suicides continue to occur in young adult males, i.e., those under 40 years. In relation to women of the same age, younger men are more likely to commit suicide. The peak difference is the 30–39 age group, in which four males commit suicide to each female. Although women are more likely to be admitted to hospital following a suicide attempt, men complete suicide in considerably greater numbers with around three to four men completing suicide for every woman. While the suicide rate for women shows a gradual increase with age, men’s suicide rate first peaks in middle adulthood, showing a marginal decline until the dramatic increase for the 75+ age group (Care Services Improvement Partnership/National Institute for Mental Health in England 2006a, National Collaborating Centre for Mental Health 2010, Da Cruz et al. 2011, Office for National Statistics 2011, De Gioannis & De Leo 2012). Among those with mental health problems, suicide is the single largest cause of premature death; 10 % of people with psychosis will ultimately kill themselves, two-thirds within the first 5 years (Wiersma et al. 1998). Around the time of emerging psychosis, young females have a 150-times higher and young males a 300-fold higher risk for suicide than the general population (Care Services Improvement Partnership/National Institute for Mental Health in England 2006b, Bergen et al. 2010, Gwashavanhu 2010).

Deliberate self-harm (DSH), formerly known as parasuicide, is a non-fatal act of self-injury or the taking of substances in excess of the generally recognized or prescribed therapeutic dose. The incidence of self-harm, of which 90 % of cases involve self-poisoning, now accounts for 100 000 admissions to hospital per year, making DSH the most common reason for acute medical admission among women aged under 60 years (Crawford 2001).

Although potentially lethal drugs are regularly consumed, the overall hospital mortality rate is less than 1 %. Ryan et al. (1996) noted that there is a significant association between suicide and previous attendance at ED with deliberate self-harm. It is now commonly held that those who commit suicide and those who undertake acts of deliberate self-harm are two distinct groups (Vaughan 1985). Box 15.4 outlines the high-risk factors associated with suicidal behaviour; Box 15.5 highlights Beck’s suicide scale, which has been used to identify the seriousness of suicidal intent; and Boxes 15.6 and 15.7 provide assessment tools of suicidal ideas and risk (Hughes & Owens 1996).

The risk of suicide is increased by a factor of 100 compared with that in the general population where there is both a recent history of deliberate self-harm and persistent, distressing suicidal ideation. Many of the suicide intent scales depend on the balance between lethality and rescuability (Pritchard 1995). Lethality is the medical danger to life; methods such as shooting and jumping from a high building have high lethality values, whereas a tranquillizer overdose will have a lower lethality value. Conversely, someone who takes an overdose of tranquillizers and alcohol and then disappears into the sea has a low likelihood of rescuability. The person who is drunk and attempts to take a large number of tablets in front of their partner has a high likelihood of rescue. The overall level of intent depends on the balance between lethality and rescuability (Jones 1995).

Obtaining a history from a client following a suicide attempt is frequently very difficult. The client may also give false information to avoid embarrassment. A client has the right to refuse treatment, and any treatment which is enforced on a client is considered assault or battery (Dimond 2004). Under common law, treatment can be given without the consent of the client in cases of necessity: circumstances in which immediate action is required and necessary to preserve life or prevent a serious or immediate danger to the client or others. The treatment or physical restraint used must be reasonable and sufficient only to the purpose of bringing the emergency to an end. Medical treatment should be administered under the specific direction of a medical practitioner (Hughes & Owens 1996). This duty is imposed by statute and the Nursing and Midwifery Council (2008) Code: Standards of conduct, performance and ethics and is underpinned by the principles of civil law relating to negligence, including the Mental Capacity Act 2005 (Gertz et al. 2006).

The feelings of ED staff towards clients with self-inflicted injuries appear to be predominantly negative (Celenza 2004). Ward (1995) recommends that the nurse seeks to make sense of the client’s behaviour from the client’s point of view, rather than the nurse’s. The key to a successful nurse/client relationship lies in establishing a positive rapport from the initial assessment. A strategy for achieving this was suggested by Burnard (1990) in relation to interviewing technique. He proposed the acronym ‘SOLER’ to remind the interviewer of the following:

This position helps to make the nurse appear warm and empathetic. By adopting this strategy the nurse should be able to dissociate herself from prejudicial feelings, and the client is more likely to feel accepted and worthwhile.

If the client is determined to be at continued risk, the nurse should not leave him alone. If the client is considered to be at high risk and is not willing to accept hospitalization, involuntary admission will be necessary. If doubt exists, caution should be exercised and admission arranged.

Individuals at odds with society (sociopathy)

Sociopathy refers to a group of well-defined anomalies or deviations of personality that are not the result of either psychotic or any other illness. Numerous theories have been put forward as to why this disorder should develop (Bowlby 1965, Cleckly 1967).

The client may present to the ED with depression, suicidal gestures, abuse of drugs, alcohol and sex, or as a result of aggressive and violent behaviour and lack of impulse control, etc. Management requires a complete history to be taken to exclude epilepsy, hypoglycaemia or any other acute organic reaction. Treatment is directed at managing the presenting condition with a firm and consistent approach. Reference to mental health teams is as appropriate.

Violent clients

Violence or threats of violence may be associated with a variety of disorders, e.g., psychosis, chemical intoxication, sociopathy, etc., or with a specific situation, such as lack of communication. The nurse should be alert for violence, particularly if the client has a previous history of violent behaviour or poor impulse control, if he has been brought in by the police or if he is verbally or physically threatening.

There are several management points in the ED:

Learning disability clients and mental health problems

Clients with learning disabilities may present with:

The client should be assessed as appropriate and a history taken from the escort. If admission is not required, referral to local learning disability services and social services may be required to provide an emergency service. If behaviour is disturbed and the client requires medications, low doses of neuroleptics should be given because of susceptibility to side-effects (see also Chapter 33).

Elderly clients presenting to the ED with mental health problems

Psychiatric emergencies arising de novo or superimposed upon dementia include:

In healthcare for the elderly, the decision as to whether to admit a client is usually made after careful assessment. Ideally, problems presented by the elderly client will be assessed by the healthcare for the elderly team (mental health) on a domiciliary visit. In reality, elderly clients may be referred or present directly to the ED. Therefore the nurse must be alert to social admission. Dementia per se is not a sole reason for admission.

Assessment should be directed towards:

If admission is necessary, the appropriate team should be contacted. If immediate treatment is required, medication should be limited to low doses, particularly if there is evidence of renal or hepatic improvement (see also Chapter 22).

Child and adolescent psychiatry

Children and adolescents will present to ED as emergency referrals. The ED nurse should be familiar with the procedure to contact the duty child and adolescent mental health team and management should be discussed with them. Any child or adolescent present with psychiatric pathology should be taken as seriously as any other age group and managed according to the presenting condition (Kaplan 2009).

Common psychiatric presentations include:

Clients attending the ED with eating disorders

The most common of eating disorders are:

Clients with eating disorders may present to the ED with problems such as osteoporotic fractures, collapse, infection, dehydration, oedema, cardiac failure, fatigue, cyanosis, bradycardia, hypotension, weight loss, obesity, hypoglycaemia, hypocalcaemia/kalaemia, infertility, amenorrhoea, constipation and vomiting, or may be referred by dental practitioners for dental problems. In addition, they may present with agitation, depression or acopia.

Social problems

Some people tend to use ED as a crisis walk-in clinic, e.g., someone who has become acutely disturbed or who is blamed as the cause of a crisis and is brought to ED as the client (Brookes & Leach 2004). Although these incidents may not be true psychiatric emergencies, the ED is seen as a 24-hour emergency unit when no other help or assistance is perceived to be available. The presence of an impartial observer and environment may enable the client and his family/carers to discuss the problems for the first time. Referral to agencies for follow-up is required, e.g., to counselling services in general and/or for specific needs, such as HIV, rape, social worker or probation officer.

Other social problems that may present to the ED are those people searching for a trolley, bed, shelter or food, often with no apparent psychiatric or medical illness. These clients can be very difficult or manipulative and require limit-setting and firm handling. The opportunity to discuss problems may help but the nurse should attempt to clarify what type of assistance the person requires and be familiar with telephone numbers of agencies able to help, such as crisis centres, social security, local hostels, emergency social workers, etc.

Acute stress reaction

This is a common, normal response to an unwanted situation and may last days to weeks and may be triggered by exposure to a traumatic event. It may develop into a more severe disorder such as simple/complex PTSD. Simple or complex PTSD can manifest itself both physically and mentally and may present with a variety of symptoms that usually appear within 6 months of the traumatic event and/or co-morbidity, e.g., alcohol/chemical dependency, sleep problems, fear and anxiety, tearfulness, sadness, helplessness, anger, irritability, guilt, concentration/memory problems, body pains, avoidance/numbness and unpleasant intrusive thoughts/flashbacks/nightmares and hypervigilance.

The onset of a stress response is associated with specific physiological actions in the sympathetic nervous system, both directly and indirectly through the release of epinephrine and to a lesser extent nor-epinephrine from the medulla of the adrenal glands. The release is triggered by acetylcholine released from pre-ganglionic sympathetic nerves. These catecholamine hormones cause an immediate physical reaction by triggering increases in heart rate and breathing, peripheral vasoconstriction or vasodilatation (see Chapter 23). In the ED, management will depend on the presenting symptoms and referral for cognitive behavioural therapy may be appropriate (National Institute of Health and Clinical Excellence 2006) (see Chapter 13).

Iatrogenic drug-induced psychosis

Non-specific psychosis may occur, including mania, delirium, schizophreniform psychosis or depression in clients on maintenance therapy for a physical condition, e.g., Cushing’s syndrome. If a client’s condition precludes reducing the dose of medication, antipsychotic agents can be administered concurrently to control symptoms.

Psychotropic drugs have served to revolutionize the treatment and care of the mentally ill. However, these drugs can also have side-effects which may require management in the ED. All antipsychotic agents may produce acute dystonias, akathisia, parkinsonism, and akinesia.

Monoamine oxidase inhibitors (MAOIs)

MAOIs inhibit monamine oxidase, therefore causing an accumulation of amine neurotransmitters. The metabolism of some amine drugs and tyramine found in some foods may cause a dangerous rise in the blood pressure. MAOIs also interact with opiates, lithium and tricyclic antidepressants. The danger of interaction persists for up to 14 days after treatment with MAOIs is discontinued.

Hypertensive crisis may occur if MAOIs are taken in combination with:

Hypertensive crisis is characterized by the sudden onset of severe throbbing headache, nausea, vomiting and dizziness. The client’s blood pressure can be as high as 350/250 mmHg, and chest and neck pain, palpitations and malignant hyperthermia, the usual cause of death in clients experiencing hypertensive crisis, may occur.

Conclusion

Psychiatric emergencies present a particular challenge to ED nurses as they may be a result of physical or functional disorders and increasingly present for the first time to EDs for initial management. There has been a recent increase in the number of liaison psychiatric nurses working within the ED. Among other responsibilities, referrals may be made to them for assessment of clients attending the ED with non-life-threatening deliberate self-harm injuries. They also have a major role in the assessment and management of behaviourally disturbed clients who are referred to the ED or are self-referrals. They have particular skills on advising on the management of psychotic or suicidal clients and can advise the ED team appropriately. This chapter has considered the more common psychiatric emergencies and identified a range of interventions for nurses to employ when caring for these distressed and frequently distressing clients. Recognizing and understanding these emergencies will help the nurse meet the challenges of psychiatric emergency care in the ED.

References