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 

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • 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