Mental health emergency

• In mental health emergency person has
• Marked disturbance of thought, mood, behaviour
• AND risk of serious physical or psychological harm to self or others
• Examples of mental health emergencies
• Acute suicidal or self-harm ideas or behaviour
• Ideas or behaviour of harm to others
• Ideas or behaviour impairing persons ability to perform usual functions of daily life
• High-risk behaviours due to mental illness
• Psychiatric/behavioural change due to urgent medical condition
• Psychological crisis due to severe stress, trauma, situational crisis

Safety

During a mental health emergency consider safety of all concerned — person, staff, carers, community people

• Assess potential risk to self and others
• If person aggressive or has weapon — keep away
• If inside — make sure person can leave room
• Ideally you should have separate exit (room with 2 doors)
• Keep person away from potential weapons
• Make sure you are not alone — get help (eg family, night patrol, police, Elders). Have them stay quietly nearby
• Limit number of people talking to person to lessen confusion
• Do not restrain person, seek police intervention if necessary

Do first

• Get help from ATSIHP, culturally appropriate leader, family who are trusted and can help to calm person
• Medical consult for advice and support as soon as possible
• Use calming techniques if appropriate/possible
• Do not promise what you can't give
• Do not persist if calming techniques appear to not be working
• Talk with person in quiet place with lots of light — speak calmly and clearly, use simple language, use interpreter if needed
• Be aware of your non-verbal cues — be calm and non-threatening with open, relaxed body posture, limit direct eye contact as it may be confronting
• Calm person — tell them you are trying to help
• The louder they become the softer you should speak
• Only have one person (and interpreter if needed) talking with them 
• Personalise situation — use person's name, acknowledge their feelings
• Work with person on a way to deal with their concern
• Advise person that use of violence may result in police involvement, if appropriate
• Person may need to be sedated straight away, or held in police custody
• Sedation and involuntary treatment should only be used if there is no less restrictive means of ensuring that the person receives the treatment and care they require
• If IV/IM sedation given — must stay in clinic for observation and airway management

Ask

• History from person, family, police, community workers
• If person has already taken any PRN medicine, eg olanzapine

Check

Only if possible and safe 

• U/A, pregnancy test
• Coma scale score if confusion or drowsiness
• Head-to-toe exam — with attention to
• Head injury, epilepsy (fits), medicine toxicity, substance use (intoxication), electrolyte imbalance, thyroid disease, infection (eg chest, ear, UTI, meningitis, encephalitis)

Do

• Mental status examination
• Urine drug screen
• Medical or mental health consult to decide if person will be managed in community or sent to hospital
• Consider hospital if
• Person getting worse
• Family, community or clinic can’t manage safely

Sedation

Always do medical consult before giving sedating medicine — if this will cause serious delay in treatment — give one dose, then do medical consult as soon as possible

• May be useful if person
• Agitated — including DTs/‘horrors’/fits from alcohol withdrawal
• Waiting for transport to hospital
• Starting treatment in community

• Sedation can be dangerous — oral sedation is the safest
• Monitor airway and breathing, REWS if able, before, during and after any sedation
• Use oral sedation unless person very agitated or refusing to take tablets — then use IM sedation. Avoid IV sedation
• Diazepam and midazolam together can put breathing at risk. Be ready to manage airway and breathing
• Do not give benzodiazepines (eg diazepam) to child or person who is very drunk. Wait 6–8 hours after last drink
• Give older people lower doses

Oral sedation

• Give diazepam oral — adult 5–10mg — repeat as needed every 2–6 hours up to 40mg/day
• OR olanzapine wafer — adult 5–10mg — repeat as needed every 2–6 hours up to 20mg/day

IM sedation

• If oral sedation not working OR person severely agitated or threatening harm — use IM medicine
• Give midazolam IM — adult 5–10mg — repeat every 20 minutes if needed up to 20mg/day
• Midazolam very short acting — consider adding longer lasting oral benzodiazepine once person settled

Other medicines

Antipsychotics

If person has psychotic symptoms — medical consult

Oral

• Usual antipsychotic medicine if prescribed — check file notes
• OR olanzapine wafer — adult 5–10mg
• OR risperidone oral — adult 0.5–2mg

OR IM

• Haloperidol IM — adult 5–10mg OR Droperidol IM — adult 2.5-5mg
• Monitor airway after giving haloperidol — risk of laryngeal (throat) spasm
• Start with lower doses for child/adolescent, older person, person who has not used antipsychotics before
• Benzatropine may be needed with haloperidol if side effects (eg stiffness, tremor, slowed movement). Less likely to be needed with risperidone or olanzapine
• Do not give IM olanzapine within two hours of IM benzodiazepines (eg midazolam)

After sedation

• Put in  wide bore IV cannula. If sending to hospital — put in cubital fossa/upper forearm to leave room for wrist restraints. Splint elbow straight
• May need fluids — BP may drop due to sedation
• Further assessment at hospital usually needed. Can be voluntary or involuntary. Not all patients will be admitted
• Medical consult to organise sending to hospital — see local protocols
• Involuntary assessment
• If person meets requirements under state/territory Mental Health Act — they can be sedated and/or restrained and sent to hospital for assessment and treatment without their permission
• Authorised by doctor or authorised/designated mental health practitioner. Always consult doctor or on-call psychiatrist

Important that you know

• Your organisation safety policy
• Your regional mental health referral and admission processes
• How to contact an authorised/designated mental health practitioner
• Your local community support
• Requirements for involuntary assessment or treatment under your state/territory Mental Health Act — mental illness, mental disturbance and complex cognitive impairment
• What needs to happen if person being sent to hospital in another state/territory
• Do not attempt to transport any person who may become violent without support and medical consult

Transport of person who is or may become violent

• Person can be transported against their wishes if they meet criteria for involuntary assessment or treatment under state/territory Mental Health Act
• If physical problems (eg head injury, delirium) — can be transported under common law
• If under guardianship — can be transported with consent of guardian

Do

• Call police for help if you believe physical safety of attendants is under threat
• Check your organisation protocols for transport of a person who is or may become violent
• Always do medical consult about assessment and management plan

For transport by air

• Air retrieval services must follow aviation regulations
• Pilot and medical team will determine if travel is safe
• Will usually involve restraint — air retrieval service, medical team and police to advise plan
• Pilot has ultimate responsibility

For transport by road

• Seat belts must be worn
• Person sits in back seat on passenger side
• Need 2 people apart from driver and person
• Helps if at least 1 escort known to person, can help keep them calm