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
• The paramedic has no powers under the Mental Health Act but the police may take an individual to a place of safety (e.g. psychiatric unit or police station) under Section 136
• Persons who appear to be actively attempting to end their own life, or seem to be about to do so, can be restrained from doing so (under common law), pending a psychiatric assessment.
Depression and mania
• Clinical depression refers to a persistent and debilitating disorder of mood characterised by sadness, an inability to derive pleasure from any activity, low self-worth and lethargy
• Patients may neglect themselves and become physically at risk through not eating or drinking
• Often depressed mood is associated with poor social circumstances and deprivation
• Manic depression is characterised by elation and overactivity with increased speed of thought and pressure of speech. They may have grandiose delusions and see themselves as being rich, famous or wealthy
• A patient suffering from manic depression may dress inappropriately or be sexually disinhibited.
Features of depression:
• Sadness
• Inability to derive pleasure from any activity
• Low self-worth
• Lethargy
• Lack of motivation
• Sleep disturbance
• Appetite disturbance
• Lack of libido
• Thoughts of guilt and self-blame.
Anxiety disorders
• Anxiety disorders include anxiety states, phobias and obsessive compulsive disorder
• Hyperventilation is the result of excessive breathing from the upper chest (ribcage) and results in hypocapnia, which causes tinnitus, tetany, tingling, weakness and chest pains
• The experience of these physical symptoms may exacerbate the feeling of anxiety, causing more hyperventilation
• An explanation of the symptoms and reassurance that the patient will not come to any harm as a result of them is the first step, and may need frequent and authoritative repetition.
• Fearfulness
• Irritability
• Difficulty in concentration
• Sensitivity to noise
• Feelings of restlessness
• Hyperventilation
• Sweating
• Increased heart rate
• Dry mouth.
Management of hyperventilation
• Make sure the patient is sitting or lying in a supported posture
• Stress the need to regulate the breathing by breathing more slowly and taking shallower breaths (not deeper ones), ideally until the patient can breathe through the nose
• Demonstrate how the patient can breathe using the diaphragm by placing one hand on the chest and one on the abdomen. The hand on the abdomen should move more than the one on the chest
• Provide ongoing explanation for the symptoms and plenty of reassurance
• Always rule out other possible causes of the symptoms (such as an acute coronary syndrome) before treating any patient for hyperventilation.
Delirium
• Acute toxic confusional state (delirium) is easily confused with psychiatric presentations. An elderly person suffering from dementia may develop a toxic confusional state as a complication
• Delirium tends to be variable in its nature, whereas dementia is altogether a more gradual and constant deterioration in functioning and behaviour
• Causes include infections such as urinary or respiratory infections or conditions such as acute urinary retention.
• Clouding and fluctuation of consciousness
• Periods of drowsiness
• Poor concentration
• Lack of lucidity
• Increased arousal
• Acute anxiety
• Fearfulness
• Disturbances in perception
• Illusions or hallucinations
• Disorientation to time, place and person.
Alcohol and illicit drugs
• It may not be easy to decide whether an intoxicated individual requires hospital assessment or (if causing a disturbance) whether police custody is more appropriate.
Beware of the drunk, head-injured patient – if in doubt, take them to hospital
• Alcoholism is often associated with conditions such as head injuries and alcohol withdrawal is a common cause of seizures
• Delirium tremens, which occurs after reduction in drinking, is characterised by tremulousness, disorientation and vivid hallucinations, is associated with a mortality of 10% and should always be managed in a general hospital
• Certain hallucinogens (such as LSD or magic mushrooms) can trigger a psychotic reaction in a previously undiagnosed or vulnerable person.
Personality disorder
• These patients are often frequent users of the emergency services
• They often harm themselves or express suicidal ideation and are frequently admitted to hospital. They may be hostile and impatient and lack the ability to form a rapport
• They appear to induce feelings of irritability and antagonism in staff and it is easy to lose an objective approach to their problems.
The Mental Health Act 1983
• If, after assessment, it is felt that a patient needs to be in a psychiatric hospital, a patient who refuses admission can be admitted compulsorily under the provisions of the Mental Health Act 1983
• The sections that are most likely to be used in an emergency are Sections 2, 3, 4, 135 and 136. The section papers must be filled in before the patient is taken to hospital
• The Mental Health Act does not apply to persons who are intoxicated by alcohol or drugs.
Section 2: Admission for assessment
•Section 2 is for assessment in hospital, or for assessment followed by treatment, and it is usually applied when a patient has no past history of mental disorder or is not known to the local psychiatric service
• The section is valid for 28 days
• The procedure requires an application by an approved social worker or nearest relative and medical recommendations by two doctors, one of whom is usually a psychiatrist.
Section 3: Admission for treatment
•Section 3 allows the compulsory admission of a patient and treatment for up to 6 months. It is usually applied when there is a known diagnosis
• The application is made by the patient’s nearest relative or an approved social worker.
Section 4: Admission in an emergency
• This Section allows for a patient to be detained for not more than 72 hours in order to obtain the second medical opinion. It is expected that it will be converted to a Section 2 as soon as possible.
Section 135
• A social worker who believes that someone is suffering from a mental disorder and is unable to care for himself, or is being ill treated or neglected, may apply to a magistrate for a warrant for that person’s removal to a place of safety.
Section 136
• It is possible that some emergency situations (such as road traffic collisions) will necessitate the removal of apparently mentally ill people to a place of safety without the possibility of obtaining applications from social workers or psychiatrists
• With Section 136, police constables have the power to remove to a place of safety a person whom they find in a public place who appears to be suffering from a mental disorder and to be in need of care and control for his own interests or for the protection of others
• The person should be taken to the nearest convenient place of safety (usually a hospital or police station) to be detained for a period not exceeding 72 hours for the purpose of examination by a doctor and interview by an approved social worker.
For further information, see Ch. 56 in Emergency Care: A Textbook for Paramedics.
