Category: Psych

Acute Behavioural Disturbance / Excited Delirium

Most of us will have seen patients like this – agitated, aggressive and often with police or security pinning them down.

  1. High risk of Cardiovascular Collapse/Death – likely due to adrenaline surge, heat exhaustion and injury. It can happen very suddenly.
  2. Keep physical restraint to a minimum – Don’t allow patient to forced face down, it’s the most likely way of killing them.
  3. Sedation – if you’re restraining you will almost certainly need to sedate. IV is best but if access is too risky IM will have to do.
  4. Aggressive management of underlying issues – esp. hyperthermia and acidosis and look out for rhabdomyolysis and DIC

Refusing treatment = Mental Capacity Assessment [LINK]


OrderDrugRouteTypical Dose (mg)Onset (min)Duration (hr)Warning
First LineLorazepam - AdultIV1mg IM/IV (max dose 4mg/24hrs)2-51-2Respiratory depression, IM unpredictable onset
IM15-30
Lorazepam-ElderlyIV0.5mg IM/IV (max dose 2mg/24hrs)2-5
IM15-30
Second Line - AdultOlanzapine (not within 1hr of IM Lorazepam)IM5mg (max dose 20mg/24hr)15-45>10Arrhythmia Risk: Only if previously used OR ECG
Second Line - ElderlyPromethazineIM10mg15-30>10
Sedation ST4+ involvement requiredKetamineIV1-2mg/kg120-30Theoretical risk of worsening cardiovascular instability
IM2-4mg/kg3-560-90

RCEM -abd

Trust Guide

Mental Capacity Act (2005)

Applies to all over 16’s

Principles

  1. Everyone is presumed to have capacity – until a lack of capacity has been established
  2. All practical efforts have been made to help patient make a decision
    • Explain decision and options as clearly and concisely as possible (be flexible)
    • Make every effort to help the person understand (language line, writing, etc.)
    • Are there others who might help them understand? (nursing, medical, family, freinds)
  3. People are free to make an unwise decision
  4. Anything done under the act MUST be in the patients best interest
  5. Carefully consider what is the least restrictive option

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Delirium in the ED

Delirium is one of a number of geriatric syndromes and has significant associated morbidity and mortality.

3 subtypes of delirium

  1. Hyperactive – easies to spot, one we are most familiar with. Characterised by agitation/aggression/hallucinations “the non cooperative patient”
  2. Hypoactive – harder to spot. Characterised by drowsiness, less responsive, vacant, sleeping more at home
  3. Mixed

Remember there is NO SUCH THING AS A “POOR HISTORIAN” !! – Just a poor clinician! If your patient is not cooperating and can’t tell you very much then you need to find out why!!! Read more

Paediatric Mental Health

The provision of out of hours mental health services for Children and young people (under the age of 18) is changing: –

Between 8pm and 9am the onsite Mental Health Liason team (RAID) will see these patients initally and help with the mental health aspects of their care. Between 9am and 8pm contact CAMHS via switchboard as normal.

Domestic Abuse

Domestic abuse can affect anyone and often its not readily disclosed on an ED admission. We must be alert to the fact some of our patients may be attending with domestic abuse. Please explore concerns and escalate if you’re unsure. Our colleagues in the Pennine Domestic Violence Group have kindly drawn this a guidance up for us.

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