The ABCDs
of
Acute Mental Health
Berri EMET Program
February 2013
Dr Peter Stuart, February 2013
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emet.learnem.net.au
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What is a
Mental Health Emergency ?
How do we approach
Management ?
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Medical Emergencies
•  Primary Survey
–  Identify immediate threats to life
–  ABCD approach
•  Secondary Survey
–  Focus on Diagnosis
–  History, Examination, Tests
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Acute Mental Illness
•  Priorities not easily defined
•  Emergency Management less obvious
•  Cause : Physical or Mental ?
•  Risk of violence / self harm
But
Acutely management focuses on life-threats
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Today’s Discussion
•  Mental Health Primary Survey
•  Assessing Risk
•  Management of Agitation
•  Identifying Medical illness
•  Detention (SA Mental Health Act)
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Clinical Case
History
•  25 year old male, brought in by police to Berri ED
•  Found wandering near river, trousers down,
shouting obscenities.
•  Last visited hospital two years ago.
•  PH : schizophrenia, managed with antipsychotic
depot injections.
•  No other history is known.
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Clinical Case
On examination
•  Alert
•  Extremely agitated
•  Confused : Incoherent speech
•  Appears to be hallucinating
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Case Discussion
History
• 
SAPOL : wandering, trousers down, shouting obscenities
• 
PH: Schizophrenia
Examination
• 
Alert / extremely agitated
• 
Incoherent speech
• 
? Hallucinating
Triage Category ?
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Assigning a Triage Category
Priority 1 = Severe immediate threat to life
Serious Danger to self / others, Violent
Priority 2 = Severe mental distress
Self harm, Severe behavioural disturbance
Priority 3 = Moderate mental distress
Suicidal ideation / Psychotic symptoms
Priority 4 = Anxiety/Depression + no suicidal ideation
Irritable but not aggressive
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Case Discussion
History
• 
SAPOL : wandering, trousers down, shouting
obscenities
• 
PH: Schizophrenia
Examination
• 
Alert / extremely agitated
• 
Incoherent speech
• 
? Hallucinating
Immediate Priorities ?
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Mental Health Primary Survey
Assess Risk
Behavioural Stabilisation
Clear medical causes
Detention ?
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Case Discussion
History
• 
SAPOL : wandering, trousers down, shouting obscenities
• 
PH: Schizophrenia
Examination
• 
Alert / extremely agitated
• 
Incoherent speech
• 
? Hallucinating
A = Assess Risk : How ?
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Risk Assessment Tool
Level 1 : High risk of injury to other persons (including staff)
Verbal Threats of violence toward another person/s (including staff)
•  Heated verbal encounters with staff
•  Attempts to inflict physical injury on another person/s (including staff)
• 
Level 2 : High risk for self harm
•  High lethality / high intention suicide attempt
•  Severe depressive illness with well planned suicidal intent
•  Very psychotic disorganised person whose behaviour places self / others at risk
Level 3 : Moderate risk for self harm
Presents as a result of a suicide attempt with moderate suicidal intent
•  Symptoms of a severe depressive illness
•  Suicidal ideation with well formed plan and / or poor social support
• 
Level 4 : Low risk for self harm
•  Suicidal ideation only. No depressive illness. No plan. Good social support.
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Case Discussion
History
• 
SAPOL : wandering, trousers down, shouting obscenities
• 
PH: Schizophrenia
Examination
• 
Alert / extremely agitated
• 
Incoherent speech
• 
? Hallucinating
B = Behavioural Stabilisation
?
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Behavioural Stabilisation
•  Verbal Management
•  Physical Restraint
•  Chemical Sedation
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Case Discussion
History
• 
SAPOL : wandering, trousers down, shouting obscenities
• 
PH: Schizophrenia
Examination
• 
Alert / extremely agitated
• 
Incoherent speech
• 
? Hallucinating
C = Clear Medical Causes
?
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Medical Causes
to Consider ?
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Clues to Medical Illness
•  Age Extremes
<12
or
>40
•  Recent medical / surgical illness
•  Rapid onset (hrs - days )
•  Disorientation / Confusion (cognitive impairment)
•  Drowsy
•  Visual or Tactile hallucinations
19 examination
•  Abnormal vital signs / clinical
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Clues to Medical Illness
Most important clues to medical illness
–  Vital Signs (inc. BSL, U/A, PERL, GCS)
–  Cognitive Assessment
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Case Discussion
(continued)
•  Patient is pacing around cubicle / poorly cooperative
•  Airway / Breathing / Circulation stable
•  Appearance :
–  Agitated : Alert with confused speech
–  Dehydrated : Dry flushed skin / Dry Mouth
–  No obvious signs of head injury evident
•  Limited vital signs obtained
–  T = 37.0 degrees C,
PR = 130 / min regular, RR = 20 / min
–  Pupils : size 6. Unreactive to light
–  BP / Sat / BSL / U/a : not obtained
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Case Discussion
(continued)
•  Patient is pacing around cubicle / poorly cooperative
•  Airway / Breathing / Circulation stable
•  Appearance :
–  Agitated : Alert with confused speech
–  Dehydrated : Dry flushed skin / Dry Mouth
–  No obvious signs of head injury evident
•  Limited vital signs obtained
–  T = 37.0 degrees C,
PR = 130 / min regular, RR = 20 / min
–  Pupils : size 6. Unreactive to light
–  BP / Sat / BSL / U/a : not obtained
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Can the patient be medically cleared ?
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Case Discussion
History
• 
SAPOL : wandering, trousers down, shouting obscenities
• 
PH: Schizophrenia
Examination
• 
Alert / extremely agitated
• 
Incoherent speech
• 
? Hallucinating
D = Detention ?
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SA Mental Health Act
•  Allows for assessment
•  Detention for fixed periods
•  Specialist Psychiatrist review
•  Requirements ?
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SA Mental Health Act
To detain a patient
•  Mental illness requiring immediate treatment
AND
•  Danger to themselves and/or others
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SA Mental Health Act
The most common mental illnesses
requiring detention are
–  Psychosis
–  Mood Disturbance (depression / mania)
–  Organic Brain Syndrome
Risk is defined in terms of risk for self harm or
risk of injury to others
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What we covered
•  Mental Health Primary Survey
•  Assessing Risk
•  Management of Agitation
•  Identifying Medical illness
•  Detention (SA Mental Health Act)
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Mental Health Primary Survey
Assess Risk (self harm / violence)
Behavioural Stabilisation
Clear medical causes
(Sedation, Restraint, Obs)
(ABCDs, Vital signs, BSL)
Detention – is detention required ?
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Clinical Case Outcome
•  Violence response called and when assembled
•  Patient is physically restrained
•  IM Olanzepine 10 mg and IM Midazolam 5mg
•  After 15 minutes patient relaxes, lies quietly
with their eyes closed but opens them with a
gentle physical stimulus.
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Clinical Case Outcome
•  Oxygen mask (10 l/ min)
•  Monitoring (Cardiac, oximetry, BP, BSL)
•  IV fluids commenced, IV Thiamine
•  ECG : Sinus tachycardia. Narrow complex.
•  Bloods : EUC, Ca++, CBP, Serum alcohol
Provisional Diagnosis ?
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Poisoning
Toxidrome ?
Appearance
–  Dehydrated : Dry flushed skin / Dry Mouth
–  Agitated : Alert with confused speech
Vital signs
–  T = 37.0 degrees C,
–  PR = 130 / min regular,
–  RR = 20 / min
–  Pupils : size 6. Unreactive to light
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Anticholinergic Toxidrome
Features
•  Tachycardia
•  Dry skin / mucous membranes
(Dry as bone)
•  Dilated pupils (Blind as a bat)
•  Confused (Mad as a hare)
•  Febrile (Red as a beet)
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Anticholinergic Toxidrome
Causes
•  Poisoning :
–  Antihistamines, Cyclic Antidepressant, Phenothiazines,
Atropine, Hyoscine, Benztropine
•  Plants
–  Toxic Mushrooms,
–  Deadly Nightshade (Atropa belladona)
–  Back henbane (Hyoscyamus)
–  Datura or Angels Trumpet
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Datura : Angels Trumpet
The word Datura comes from Hindi dhatūrā (thorn apple)
Common names include jimson weed, Hell's Bells, Devil's weed,
Devil's cucumber, thorn-apple (from the spiny fruit), pricklyburr
(similarly), angel's trumpet and devil's trumpet
(from their large
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trumpet-shaped flowers)
Summary
The ABCDs of
Acute Mental Health
35
What is a
Mental Health Emergency ?
How do we approach
Management ?
36
Acute Mental Illness
•  Priorities not easily defined
•  Emergency Management less obvious
•  Cause : Physical or Mental ?
•  Risk of violence / self harm
But
Acutely management focuses on life-threats
37
Mental Health Primary Survey
Assess Risk (self harm / violence)
Behavioural Stabilisation
Clear medical causes
(Sedation, Restraint, Obs)
(ABCDs, Vital signs, BSL)
Detention – is detention required ?
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The ABCDs
of
Acute Mental Health
Berri EMET
February 2013
Dr Peter Stuart, February 2013
39