Category: Psych

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

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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Mental Capacity Act (2005)

Applies to all over 16’s


  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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Safeguarding Adult & Child

Safeguarding is massively important but often not done!

This can be due to lack of recognition OR not knowing what help there is. Often our imput can significantly change lives

This guide contains info on:

  1. CAMHS (child and adolescent mental health services)
  2. MARAC (domestic abuse)
  3. FGM
  4. Sexual Exploitation
  5. Human Trafficking
  6. Restraint ( see acute behavioural disturbance guide)
  7. Capacity & Consent
  8. Drug & Alcohol


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

DrugRouteTypical Dose (mg)Onset (min)Duration (min)Warning
MidazolamIV2-51-530-60Respiratory depression, IM unpredictable onset
HaloperidolIV5-1010180-360Arrhythmia Risk: Only if previously used OR ECG
KetamineIV1-2mg/kg120-30Theoretical risk of worsening cardiovascular instability


CAMHS – referral

Unlike RAID, our colleagues in CAMHS won’t take referrals form nursing staff. So there is no point arguing about it. A Dr or ACP will need to see the patient fill the form out and phone CAMHS.

Out of hours provision has changed from 21st Jan 2019



Out of Hours Provision – Change 21-1-19

In short between 23:00-09:00 CAMHS are unable to provide face-to-face consultations any longer. If the patient is:

  • Under 16yrs (16 & 17yrs will still be seen by RAID)
  • Medically fit for discharge

CAMHS will be able to provide a telephone consultation at the time, to agree a management plan either admission to Paeds or discharge with CAMHS follow up (if a Mental Health Assessment is required the duty psychiatrist will be contacted)

If discharged ensure family have the Contact Slip

seaRch: camhs