Acute Psychiatric Emergencies (eBook)

A Practical Approach

Mark Buchanan, Damien Longson (Herausgeber)

eBook Download: EPUB

2025 | 2. Auflage
307 Seiten
Wiley (Verlag)
978-1-394-28627-0 (ISBN)

Infos

An essential guide to the emergency treatment of mental health crises

Hospital emergency departments are encountering increasing numbers of patients in mental health crises and the number continues to rise year on year. Despite these challenges, very few practitioners are trained specifically to deal with mental health crises.

Acute Psychiatric Emergencies (APEx) meets this need with a course designed jointly by leading psychiatry and emergency medicine specialists with years of practical experience. It will help in any crisis setting be it in the emergency department, ward, clinic or in the community.

APEx provides a structured approach for the assessment and management of acute mental health emergencies, discusses common presentations, as well as legal frameworks and human factors. Now fully updated to reflect new guidelines and expanded treatment of key subjects, it is an invaluable resource for any practitioner involved in the provision of psychiatric care at any point in the healthcare pathway.

Readers of the second edition of Acute Psychiatric Emergencies will also find:

• Detailed discussion of topics including organic causes for behavioural disturbances, special circumstances and more
• Updated algorithms and figures for improved accessibility
• An emphasis on close cooperation between emergency and mental health teams

APEx is ideal for emergency physicians, psychiatrists, emergency and mental health nurses, paramedics and other crisis care professionals.

Advanced Life Support Group (ALSG) is an organisation dedicated to improving outcomes for people in life-threatening situations, anywhere along the healthcare pathway, anywhere in the world. A leading medical education charity, ALSG has delivered advanced life support training to over 225,000 clinicians in 44 countries.

Advanced Life Support Group (ALSG) is an organisation dedicated to improving outcomes for people in life-threatening situations, anywhere along the healthcare pathway, anywhere in the world. A leading medical education charity, ALSG has delivered advanced life support training to over 225,000 clinicians in 44 countries.

Textauszug

CHAPTER 2
Primary unified assessment and immediate psychiatric management

Learning outcomes

After reading this chapter, you will be able to:

• Explain how to assess someone who is acutely disturbed
• Describe how to take structured steps to ensure safety and minimise any potential harm to others

2.1 Introduction

The effective management of an acutely disturbed patient who has a presumed mental health crisis is a key emergency skill. By using the basic techniques and strategies described, a safe framework can be established, from which a more detailed assessment or intervention can then be carried out. It is essential that all staff who work in an acute hospital setting have these basic skills.

In the structured approach, the person who is acutely disturbed should have a primary assessment that includes ABCD and AEIO risk assessments (see Figure 2.1). It may not be possible to carry out a full physical assessment because of the level of disturbance, but consideration should be given to physical status and potential organic causes of the presentation.

In this chapter, we focus on the mental health assessment, but physical factors should always be considered and accompanied by a parallel physical assessment when appropriate.

2.2 Preparation

Never approach a patient who is acutely disturbed by yourself. Wait until a sufficient number of appropriately trained staff, police officers or security guards are present. The number required will depend upon the physical threat from the patient, the nature and degree of their disturbance, and the environment and resources of the facility in which you are working.

In most circumstances, there is time to gather information quickly before seeing the patient (e.g. if the patient is brought to the Emergency Department (ED) by the family, the police or the paramedic emergency service). The aim at this point is to access relevant information that will inform the rapid assessment.

Information may include verbal accounts from the family, paramedics, police, relevant others and the hospital record systems. Ask and obtain answers to the following questions:

• Can you tell me about the behaviour of X whilst in your care?
• On a 10 point scale (0 being not disturbed at all, to 10 being extremely agitated/violent/aroused) how would you rate this person’s behaviour?
• Can you tell me about/give me an example of the most extreme or disturbed level of behaviour you have witnessed?
• Do they speak the local language and, if not, what language do they speak?

Many mental and physical health, social care and police record systems have specific, designated subsections for flagging information about ‘risk of harm to self and others’. Attempts should be made to gain as much information about the patient as possible. Ensure all relevant information is shared between all staff involved with the patient.

Key factors to note are:

• A prior history of self‐harm
• A prior history of harm to others
• Alcohol and illicit drug use
• Prior history of severe mental illness
• Prior history of violence, forensic history (mental health treatment in a secure setting because of criminal behaviour) or a criminal record

Table 2.1 AEIO assessment: minimum number of staff required for safe containment (this is suggested safety levels)

Arousal/agitation	Environment	Intent	Objects	Containment

Low

Low

Low

Low

Nil

Moderate

Low

Low

Low

One staff

Moderate

Moderate

Low

Low

Two staff

Moderate

Moderate

Low

Moderate

Three staff

Moderate

Moderate

Moderate

Low

Three staff

Moderate

Low

Moderate

Moderate

Three staff

High

Low

Low

Low

Three staff

High

Low

High

Low

Four staff

High

High

High

Low

Six staff

High

High

High

High

Six staff

Before entering a room with an agitated patient, make sure you have back‐up in terms of available staff who can help if necessary. Have at least two other members of staff with you. There may already be staff or police officers in the room. Stay close to the door and keep it open. Do not allow yourself to be trapped behind the door. Consider the staffing recommendations in Table 2.1.

Make sure there is a way to sound an alarm, if needed, with a suitable response. Many ‘safe rooms’ in EDs do not have alarms because of inappropriate, frequent use. Make sure you have a personal attack alarm or that there is someone outside the room who can call for back‐up.

It is usual for most patients to undergo triage from a member of the ED nursing staff soon after they present. However, if patients are either very physically unwell (for instance if they have stabbed themselves) or are significantly behaviorally disturbed, it may not be possible to do this. Do not assume that aggression or agitation is due to mental health issues; most aggression within acute settings is not related to a mental health crisis. Seek relevant physical health signs or symptoms that need to be addressed.

The structured approach is universally applicable to the management of all psychiatric emergencies in all settings and across the age spectrum.

2.3 Primary assessment: the Unified assessment

Figure 2.1 Structured approach: primary assessment

The first priority is to ensure that the patient is kept safe (both physically and psychologically) whilst they are awaiting detailed psychiatric assessment or are undergoing physical investigations. They must be prevented from either intentional or unintentional harming of themselves or others. A fast and focused assessment (Figure 2.1) is required to:

• Establish the level of physical and psychiatric risk using AEIO (see Section 2.5)
• Put in place appropriate measures to minimise that risk

Observe the patient. Note their conscious level, degree of agitation and current behaviour. When it is safe to do so introduce yourself:

• ‘I’m X, I’m a doctor/nurse, I’m here to try and help you’
• Ask the patient their name and what they like to be called
• Ask them if they know where they are
• If they do not know, explain they are in a hospital, they are safe, and you are here to try and help them

As you are doing this, make a quick assessment of the patient’s overt physical health. Look for skin colour (pallor or flushed), whether or not they are sweating, pupil size (pinpoint or dilated), any obvious injuries and any signs of self‐harm (ligature mark around neck, scars to arms) or disabilities.

Ask the patient if they are hurt or in pain. If they respond positively, you will need to get details of their concerns to establish the nature of the injury or their physical health problems. Ask them if it would be okay for someone to check their pulse, temperature and blood pressure.

As you are doing this, make an assessment of their cognitive function, including basic orientation and attention.

• Can they give you their name and address and date of birth?
• Do they know where they are?
• Do they know the time of day, month and year?
• Do they understand questions?
• Do they respond appropriately?

Tell them that you need to ask them some brief questions to check that they are safe. Tell them that these are routine questions.

2.4 Primary physical risk assessment

The primary physical risk assessment should focus on four key areas:

ABCD problems should be addressed as soon as they are identified. It is not in the scope of this book to describe the life support techniques that might be necessary – patients should be moved to the resuscitation area as soon as possible and physical resuscitation should be continued there whilst the AEIO assessment described below is carried out.

2.5 Primary psychiatric risk assessment

The primary psychiatric risk assessment should focus on four key areas:

This enables staff to carry out a quick assessment of risk of harm (to self or others) and of flight risk. This enables planning of a risk reduction and containment strategy, which may or may not involve rapid tranquillisation.

Agitation/Arousal

This assessment depends on a quick observation of the patient. Their level of arousal or agitation is determined according to the following guide. Ensure that you have considered the most agitated the patient is known to have been (either during this episode or in previous episodes) as well as their current...

Produkt-Details

• Erscheint lt. Verlag: 7.3.2025
• Reihe/Serie: Advanced Life Support Group
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Notfallmedizin
• Schlagworte: alcoholism • Eating Disorders • Emergency Department • Emergency Medicine • emergency nursing • medical mimics • medical presentation • Mental distress • Mental Health • Mental Health Nursing • Pediatric health • psychiatric presentation
• ISBN-10: 1-394-28627-9 / 1394286279
• ISBN-13: 978-1-394-28627-0 / 9781394286270