Professional Documents
Culture Documents
SURVIVAL MANUAL
UNIVERSITY OF BRITISH COLUMBIA
ORIGINALLY DRAFTED
2013
LAST UPDATED
AUGUST 2014
ORIGINAL AUTHORS
DR. ARUN JAGDEO
(PSYCHIATRY RESIDENT)
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TABLE OF CONTENTS
SECTION 1: SAFETY, DUTIES, CONFIDENTIALITY, AND CERTIFICATION!
CERTIFICATION !
ADMISSION ORDERS!
10
11
12
13
ANTIPSYCHOTICS!
13
ANTIDEPRESSANTS!
14
MOOD STABILIZERS!
15
ANXIOLYTICS!
16
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Learn what you can about the patient before the interview; talk to nursing staff, review chart.
Be mindful of unpredictability in patient behaviour. Some factors to consider are intoxication, withdrawal,
persecutory delusions and previous assaultive behaviours.
Maintain physical distance in interview.
Interview in a room with a window so that youre at least semi-visible. Some rooms use television rather
than windows; in these rooms maintain visibility in the camera field of view.
Be aware of personal or desk alarms in case of emergency in interview.
Be aware of code white procedures.
Maintain close proximity to the door.
Consider nurse as safety chaperone.
Dont wear things that can be turned into a weapon, i.e. scarf, neck tie.
YOU
INFORMATION EXCHANGE
PATIENT
CERTIFIED
PATIENT
UNCERTIFIED
OTHER
PARTIES
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CERTIFICATION
WHAT
1) INVOLUNTARY HOSPITALIZATION
WHO
WHY
ii.PROTECT OTHERS
4) PREVENT DETERIORATION OF PATIENTS MENTAL
ILLNESS
5) UNSUITABLE AS VOLUNTARY PATIENT
FORM 4
HOW
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age
living situation
relationship status
financial status
current episode
financial
onset, duration, course
impact on function
baseline function
stressors
why presenting to ER now
screen
mood symptoms
anxiety symptoms
psychosis
substance use
current treatments
medications
psychotherapy
current involvement with mental health workers
past episodes
previous diagnoses
diagnoses
hospitalization history, Voluntary Status versus
Involuntary Status
previous
medication trials, efficacy, side effects
ECT
current substance abuse
history of substance abuse
suicide attempts
MEDICATIONS
ALLERGIES
PERSONAL HISTORY
HOW
explain to patient
how long the interview will be
what you will ask about
who youll review your case with
conduct interview and review with staff
communication with nursing and allied health is
important
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MANIA
SIGECAPS
DIG FAST
Suicidal thoughts
Interests decreased
Guilt
Energy decreased
Concentration decreased
Appetite disturbance
Psychomotor changes
Sleep disturbance
ALCOHOL ABUSE
CAGE
WORRY WARTS
Wound up
Worn-out
Absentminded
Restless
Touchy
Sleepless
BORDERLINE PERSONALITY
DISORDER
ANTISOCIAL PERSONALITY
DISORDER
IMPULSIVE
CORRUPT
Distractibility
Indiscretion
Grandiosity
Flight of ideas
Activity increased
Sleep deficient
Talkativeness
GENERALIZED ANXIETY
DISORDER
Impulsive
Moody
Paranoid
Unstable self-image
Labile intense relationships
Suicidal gestures
Inappropriate anger
Vulnerability to abandonment
Empty feeling
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SPEECH
THOUGHT FORM
PERCEPTIONS
delusions
ideas of reference
obsessions
magical thinking
paranoia
realistic concerns / worries
suicidal ideation
homicidal ideation
INSIGHT
THOUGHT CONTENT
hallucinations
derealization
depersonalization
COGNITION
EMOTIONAL STATE
goal directed
coherent versus disorganized
tangential
circumstantial
flight of ideas
loosening of associations
awareness of illness
absent
poor
partial
impaired
complete
JUDGMENT
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ADMISSION ORDERS
SAMPLE TEMPLATE
EXAMPLE
1.
2.
3.
4.
5.
6.
7.
8.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14. Withdrawal protocols
15. e.g. CIWA, Nicotine Replacement Therapy (patch,
etc.)
16. Order charts from other hospitals, if necessary
9.
10.
11.
12.
13.
14.
15.
16.
shorter
may be during off-hours
focus on history of presenting illness
4Ss
Stressors
Suicide
Substance use
pSychosis
psychosis
suicide
drug-induced psychosis
mania
severe depression
depression with psychotic features
dementia
personality disorder
review chart
review vital signs
review blood work drawn
talk to Registered Nurse, especially query safety risks in seeing patient by yourself
SAFETY FIRST
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Assessment
can use CASE (Chronological Assessment of Suicide Events) to evaluate risk 24 hours leading up to thought or event
? suicide note
? tell anyone
? purchase instrument of death
now ask about last month
Document
intent
lethality and access
review risk factors SAD PERSONS
Sex (male > female)
Age (risk with age)
Depression
Previous attempt ** (best indicator of suicide risk)
Alcohol abuse
Rational thinking loss (impulsive)
Social supports lacking
Organized plan
No spouse
Sickness
protective factors
children
social supports
religious
good health
pregnant
sense of responsibility
consider the following in your decision to discharge
diagnosis
severity of suicidal ideation
coping skills
living situation
social supports
risk factors
access to follow-up
References
SAD PERSONS mnemonic adapted from: Patterson WM, Dohn HH, et al: Evaluation of suicidal patients, THE SAD
PERSONS Scale, Psychosomatics, 1983.
Some content adapted from Emergency Psychiatry lectures by Dr. Levy and Dr. Sadrahasemi.
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Assessment
previous psychotic episodes
patient medically cleared?
is it safe to see the patient?
presence of delusions; note the themes
presence of hallucinations
ask specifically about COMMAND HALLUCINATIONS, as this is a significant risk factor for completed suicide
thought form disordered?
suicidal ideation or homicidal ideation
substance abuse?
conduct and document a thorough mental status examination
get collateral: (current psychiatrist, mental health team, G.P. family, friends regarding recent mental state and functioning,
to establish a patients baseline)
Investigations
CBC with Differential
Electrolytes
BUN/Cr
TSH
Liver Function Tests (AST, ALT, ALK, GGT, Total Bilirubin, Direct Bilirubin)
Urine Drug Screen
Serum Drug Screen
Consider, where warranted
Extended electrolytes (Ca, Mg, PO4)
Vitamin vitamin B12
VDRL
Lipids
Fasting Glucose
Head-CT
EEG
EKG
Beta-HCG if female, where appropriate
Management
Often restart antipsychotic medications
Consider
seclusion PRN and restraints PRN where warranted
PRN orders for agitation, withdrawal from substances
Factors pointing to possible organic cause of psychosis
Elderly patient, first episode
Current medical illness
Recent drugs (prescription or street)
Acute onset (within minutes to hours)
Non auditory hallucinations
Neurological signs
headache
neurological deficits (e.g speech, movement)
vision changes
gait changes
Fluctuating attention and concentration
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Assessment
previous psychiatric diagnoses
previous hospitalization
previous hypomanic episodes
on mood stabilizers or antidepressants
adherence to medications
does the patient meet criteria for mania?
recent stressors, precipitating events
screen for
psychotic features
substance abuse
other comorbid conditions
presence of suicidal ideation/homicidal ideation
insight and Judgement intact?
obtain collateral
MSE (mental status examination)
elaborate fashion
pressured speech
psychomotor agitation
euphoric mood or irritable
labile affect
flight of ideas
grandiose thoughts
insight/judgement generally poor
is the patient medically cleared?
review most recent vital signs
review blood work
review investigations already ordered by ER
rule out organic causes
ensure that it is safe to see the patient (review safety guidelines)
Investigations
if on Lithium
CBC with Differential
electrolytes
BUN/Cr
TSH
Beta-HCG
EKG
Lithium level
if on Valproic Acid
same as above + liver panel
consider extended electrolytes
Acute Management
certify and admit the patient
consider potential for aggression or violence and order seclusion orders accordingly
restart mood stabilizer
may need low dose antipsychotic agent
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Whos at risk?
Patients abruptly stoping or reducing alcohol intake after heavy or prolonged alcohol use.
Investigations
CBC with Differential
electrolytes
BUN/Cr
Ca, Mg, PO4
Liver Function Tests (AST, ALT, ALK, GGT, Total Bilirubin, Direct Bilirubin, Albumin, INR, PTT)
Beta-HCG where appropriate
consider EKG
STI testing
Signs Or Symptoms
ANS instability (fever, tachycardia, sweating, hypertension)
tremor
nausea/vomiting
auditory hallucinations / visual hallucinations
agitation
anxiety
seizures (generalized, tonic-clonic)
Complications
seizures
alcohol hallucinosis
delirium tremens
Management
benzodiazepines
monitor using CIWA (Clinical Institute Withdrawal Assessment) protocol
Thiamine 100mg PO once daily x 5 days
1 multivitamin PO daily
Magnesium sulphate 2g IV x 1 if tremulous
replenish extended electrolytes as needed
rule out UTI, pneumonia
consult addictions
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ATYPICAL
HIGH POTENCY
MEDIUM POTENCY
Loxapine 10 to 250mg
Olanzapine 5 to 30mg
Ziprasidone 40 to 80mg PO twice per day
Aripiprazole 10 to 30mg
LOW POTENCY
SIDE EFFECTS
EPS
TREATMENT OF EPS
anticholinergic
dry mouth
confusion
dry eyes
urinary stasis
antihistaminic
sedation
weight gain
antiadrenergic
orthostatic hypotension
erectile dysfunction
metabolic side effects
type II diabetes
weight gain
cardiac
prolonged QT
rare NMS (neuroleptic malignant syndrome)
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ANTIDEPRESSANTS
SSRI (SELECTIVE SEROTONIN REUPTAKE
INHIBITOR)
NASAA
SIDE EFFECTS
SIDE EFFECTS
weight gain
sedation
SIDE EFFECTS
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MOOD STABILIZERS
VALPROIC ACID
LITHIUM
SIDE EFFECTS
SIDE EFFECTS
Olanzapine | Zyprexa
Quetiapine Fumarate | Seroquel
Risperidone | Risperdal
leukocytosis
weight gain
hypothyroidism
tremor
teratogenic
nephrogenic diabetes mellitus
nausea/vomiting
cardiac side effects
acne
psoriasis
toxicity: ataxia, dysarthria, myoclonus, mental status
changes, seizures, coma; dialyze if serum level > 2
SIDE EFFECTS
click to scroll up
OTHERS
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ANXIOLYTICS
FIRST LINE
SSRI (SELECTIVE SEROTONIN REUPTAKE
INHIBITOR)
GAD only
5-HT1A agonist
SIDE EFFECTS
SIDE EFFECTS
OTHERS - BENZODIAZEPINES
nausea
diarrhea
weight fluctuations
sexual dysfunction
headache
dizziness
sleep disturbance
SIADH in the elderly
nausea
headache
dizziness
EPS
ADVERSE EFFECTS
tolerance
dependence
can worsen delirium
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