Table 14.3 Common features indicating a person \200\231s mood Common symptoms d Self-esteem and self-con \201 dence d Concentration and attention Memory disturbance (esp short-term) Bleak and pessimistic views of the future Ideas of self-harm or suicide Feelings of guilt or worthlessness Somatic or vegetative symptoms Sleep disturbance d Appetite Weight loss Constipation Amenor rhoea Loss of interest or enjoyment Look for self-neglect. Does the patient exhibit psychomotor retardation (slow movements and speech) or is he agitated? Is eye contact maintained? Are there de \201 cits of short-ter m memory and cognition that improve with i effort? Psychotic symptoms occur in very severe cases (eg hallucinations or delusions). These are mood congruent: derogatory voices, ideas of poverty, guilt, nihilism (patient believes he has no bowel, no clothes, no life, etc.). Anxiety can be a feature of depression. Atypical depression can involve reversal of usual s omatic symptoms leading to i appetite, i weight, hypersomnia, and reversed diurnal mood var iation. Treatment Arrange psychiatric assessment for patients with severe depression , suic idal ideation, or psychotic features. Most respond to antidepressants, but do not start the se in the ED. Some patients also require antipsychotics or ECT. In cases with psychotic fea tures or where there is a high risk of death from suicide or profound self-neglect, ECT is effective. Mild/moderate cases may respond to psychological therapy. Counseling can help sp eci \201 c problems (eg bereavement or marital dif \201 culties). 617 MANIA Mania Mania and hypomania are less common than other mood disorders, but more often require compulsory hospital admission. Pathologically elevated mood combines with over-activity, i rrationality, poor judgment and lack of insight (see Table 14.4 for primary and other featu res). This leads to severe disruption of relationships, employment or \201 nances. Untrea ted, high rates of divorce, debt, violence, or suicide occur. Onset may be acute or insidio us. Manic disorders can arise spontaneously or follow depressive illness, stress, surgery, infection, or childbirth. Antidepressant medication, ECT, steroids, and amphetamines can al l precipitate mania, as can lithium withdrawal. Table 14.4 Primary and other features of mania Primary features Over-cheerfulness Over-talkativeness Over-activity Other features Irritability Flight of ideas Distractibility Grandiosity d Requirement for s leep Delusions (mood-congruent) Hallucinations Impaired judgment Irresponsibility and impet uousness Gambling and promiscuity Hypomania hallucinations or complete disruption of normal activities. denotes an intermediate state without delusions, Differential diagnosis Schizophrenia can present with disorganized behavior, violent excite ment, delusions, and incomprehensible speech. The content of delusions (ie bizarre, rather than mood-congruent), will help distinguish this from mania. Approach to the patient Stay calm and non-confrontational. Beware infectious optimism, whic h can easily lead to underestimating the severity of illness or the requirement for admissi on. Seek additional information from relatives. Irritability can be the dominant symptom of mania and may be expressed as a savage, highly detailed catalog of the interviewer \200 \231s shortcomings. Irritable patients can become angry or violent in the face of even mino r frustrations. Treatment Overt manic illness is best managed in hospital to avoid behavior harmful to the patient or others. Insight is often d or absent, so compulsory admission may be required. L iaise with the psychiatrist before commencing de \201 nitive drug treatment as this may ad versely affect assessment. Lithium carbonate is traditional and effective in most cases, bo th to treat the acute episode and as prophylaxis against recurrent mania. However, it usual ly takes some days to work, so an antipsychotic (eg olanzapine) or benzodiazepine may be ne eded initially. 618 CHAPTER 14 Psychiatry Schizophrenia This affects all areas of personal function, including thought content and pr ocess, perception, speech, mood, motivation and behavior. A common pattern is acute exacerb ation with i residual handicap between episodes. 30 % of those who suffer a \201 rst epis ode never have another. Another 30 % develop chronic symptoms requiring frequent admission or long-term care. The lifetime risk is 1/100. Clinical features No single symptom is pathognomonic: hallucinations or delusions simply co n \201 rm psychosis. Schneider \200\231s First Rank Symptoms originally suggested schizoph renia in the absence of organic disorder. It is now acknowledged that they can occur in man ia and other conditions: \200 Auditory hallucinations \211 2 voices discussing the subj ect in the third person or giving a running commentary on his/her thoughts/behavior. Thought withdrawal, insertion, or broadcasting. \200 Somatic passivity sensations, emotio ns, or actions are externally imposed or controlled. Delusional perception a genuine perception takes on abnormal signi \201 - cance for the subject and is the basis of their delusional system. Gedankenlautwerden voices repeating the subject \200\231s thoughts out loud or anticipating the subject \200\231s thoughts. Diagnosis Mental state examination will help to exclude organic and affective disorders, re membering: \200 Non-auditory hallucinations are more common in organic conditions. \200 Delusions in depression and mania are mood-congruent. Differential diagnoses Organic cause s: temporal lobe epilepsy, drug-induced states, alcoholic hallucinosis, cerebral tumor, enc ephalitis, head injury. Psychiatric: affective psychoses, schizo-affective disorder, psychogenic psychosis, delusio nal disorder (eg infestation), personality disorder. Management Patients not known to have schizophrenia Refer to the psychiatric team who will advise about the need for urgent antipsychotic treatment. Patients known to have schizophrenia Schizophrenics frequently present to the ED with menta l health issues and problems. It can be dif \201 cult to formulate a management plan unles s relevant background information is available. Liaise with relevant individuals (including community psychiatric nurse and psychiatrist) to decide whether to treat in hospital or in the community and what form any treatment should take. 619 COMPLICATIONS OF PSYCHIATRIC DRUGS Complications of psychiatric drugs Antipsychotic drugs Acute dystonic reactions (grimacing, facial, and masseter spasm, deviated gaze, torticollis, limb rigidity, and behavioral dist urbances) frequently present to EDs. They follow ingestion of antipsychotics (eg phenothiaz ines or haloperidol) and/or other drugs (eg metoclopramide), even in therapeutic dosages. R eactions can occur up to 1 week after ingestion. Acute dystonia can dislocate the mandible. Dystonia can be mistaken for malingering, as symptoms can be brie \202 y interrupted by v oluntary actions. Once diagnosed, treat with : Procyclidine 5 mg IV bolus, repeated as necessary after a few minutes. Dramatic resolution of symptoms occurs within minutes, con \201 rming the diagnosis. Sympt oms may recur \200\224 treat with oral procyclidine 5mg every 8hr. Large doses of procycli dine cause euphoria and \201 xed dilated pupils, hence, its abuse by some patients. Diaze pam also works, but is less speci \201 c and carries risks of excessive drowsiness or resp iratory depression. Clozapine An atypical antipsychotic used in treatment-resistant schizophrenia. Agranulocyto sis occurs in 3 % of patients. For this reason, all patients are enrolled with the Clozaril Patient Monitoring Service (telephone 0845 769 8269) who supervise regular blood screening . Check FBC for neutropenia in any patient presenting with fever, sore throat, or other inf ection. Monoamine oxidase inhibitors (MAOIs) MAOIs (eg phenelzine, tranylcypromine), irreversibly b lock enzymes responsible for oxidative metabolism of 5HT, noradrenaline, tyramine, and othe r amines. Once discontinued, enzyme inhibition continues for up to 2 weeks, during which ti me other drugs should not be intro- duced. Newer, reversible MAOIs ( \200\230RIMAs \200\231 \200\224 eg moclobemide) cease to have effects after 24 \200\22348hr. MAOIs cause postura l hypotension, but acute hypertensive reactions follow ingestion of amine rich foods (eg Bo vril TM , Marmite TM , cheese, red wine). Noradrenaline release causes vasocon- striction, tachycardia, and hypertension that can, in severe cases, lead to intracerebral or subarachn oid hemorrhage. Similar hypertensive crises can be caused by concurrent use of L-dopa, symp athomimetics, ampheta- mine, or drinking certain low-alcohol beers or wines. Lithium Lithium toxicity presents with severe nausea, vomiting, cerebellar signs, or confus ion. SSRIs (eg \202 uoxetine), anticonvulsants, antipsychotics, diuretics, methyldopa, an d calcium channel blockers can all precipitate toxicity. Look for tremor, cerebellar ataxia , muscular twitching (myoclonus), spasti - city, choreiform movements, up-going plantar res ponses, incoordina tion, slurred speech, impaired concentration, drowsiness, coma. Check se rum lithium (plain, not lithium heparin tube!) and U&E immediately. Serum lithium levels co rrespond poorly with clinical signs (toxicity can occur within therapeutic range), so diagn osis of toxicity is based on clinical observations. Stop lithium and treat according to sev erity of toxicity ( b p.197). 620 CHAPTER 14 Psychiatry Munchausen \200\231s syndrome Also known as \200\230hospital hopper \200\231, this is char acterized by recurrent hospital admissions with factitious symptoms and signs of physical i llness. Other basic components are a morbid attraction to the sick role, pathological lying and pleasure from deceiving medical staff. The incidence is unknown, but it is prob- ably underestimated. It is believed to be commoner in men with peak onset at 30 \200\22340 years . There may be an underlying personality disorder, but true psy- chiatric illness is rare. Origins are uncertain: excessive dependency, inability to form trusting relationships, atte ntion-seeking, childhood hospitalization, and resentment of doctors for previous treatment have all been suggested. Presentation Common presentations involve detailed and convincing descriptions of cardiac chest pain, abdominal pain (especially pancreatitis), haematemesis, haemoptysis, rectal bleeding, haematuria, or pyrexia. More rarely, patients present with a rtefactual dermatitis or with a dramatic history of trauma (eg fall or pedestrian knockdown ). Distinguish Munchausen \200\231s from: \200 Malingering: fabricating illness for de \201 nite gain (eg stealing drugs, avoid- ing court appearance, faking symptoms to obtain opioids). Somatoform disorders: physical symptoms or signs without organic cause, but not under voluntary control. Fabricated and induced illness: see b p.733. Suspicious features \200 Incomplete or incon sistent disclosure of personal details and past history. \200 Patient a long way from hom e area for unclear reasons. \200 Recent dramatic history of myocardial infarction (MI), s urgery, or complications elsewhere. Excellent knowledge of \201 ner details of past treatment and/or complications. \200 Mu ltiple scars : laparotomies, sternotomy, venous cutdowns. \200 Elaborate history of aller gy (eg allergic to all painkillers except pethidine). \200 Unconvincing claims of medical or paramedical occupation. \200 Unusual/demanding behavior and/or avoidance of eye conta ct. \200 No ascertainable organic cause for the symptoms. Management Early recognition is important, but \201 rst exclude genuine illness. There may be no alternative to admissio n and observation to make the diagnosis, even though this achieves the patient \200\231s ai m. If suspicions are aroused, discreetly check past history. Once discovered, most patients self-discharge, often noisily, but rarely violently. Avoid a \200\230showdown \200\231 Si mply state that deception is at an end, that no retribution is planned and offer to help th e patient with their problem. Do not use placebos to uncover fabricated illness \200\224 t hey can work equally well on genuine symptoms! Once discovered, record events carefully, pa rticularly the medical history given, background details, appearance, scars. Circulate deta ils to other EDs. Factitious disorder in health care workers The Clothier report (Department of Health, 1994) advised that patients with severe personality disorder (by inference, factitious disorder) should be prevented from working in health-related disciplines. Detection of factitious di sorder in health care workers has serious implications. If suspected, discuss immediately w ith the ED consultant. 621 MEDICALLY UNEXPLAINED SYMPTOMS Medically unexplained symptoms Background A signi \201 cant proportion of patients who att end the ED have symptoms for which no cause is found. Some of these patients manage to buil d up a signi \201 cant volume (or volumes!) of medical records. Terminology There is a potentially confusing range of terms in use. Somatization Physical symptoms with presumed psychological origin. Somatoform pain disorder Persistent, severe unexplained pain, which is attributed to psycho logical disorders. Conversion (dissociative) disorders Loss or disturbance of normal motor or sensory function , which is attrib- uted to a psychological origin (thoughts/memories to the conscious mind are \200\230converted \200\231 into physical symptoms (eg amnesia). Factitious symptoms Symptoms which are intentionally produced, with the aim of receiving a medical diagnosis \200\224when there is secondary gain (eg legal compensation, obtaining op ioid drugs), it is known as malingering . Medically unexplained symptoms This is an umbrella term, which makes no assumptions about t he cause of the symptoms. Differential diagnosis Patients who present acutely with medically unexplained symptoms may be suffering from a range of problems, including: anxiety, depres- sion, psychosis, \200 \230functional somatic illness \200\231, conversion disorders, factitious disorders, maling ering, and uncommon medical syndromes that have not yet been diagnosed. Approach to patients with medically unexplained symptoms The Royal College of Psychiatrists ( www.rcpsych.ac.uk ) has published some useful recommendations. Consider the following: \200 Try to obtain past medical and psychiatric records/summaries (computerized records ma y assist in this process) and/or speak to the GP. If the patient \200\231s medical complaints are known to be unexplained (or part of a psych iatric illness), then further investigations may be inappro- priate. Investigate judiciously \200\224 do not underestimate the ability to cause iatro- genic harm. 622 CHAPTER 14 Psychiatry Alcohol abuse Alcohol-related problems account for up to 15 % of the ED workload in the UK. Alcoholics have i rates of heart disease, malignancy, and stroke, but often succumb to inj uries. Excessive alcohol consumption is a feature of 30 % of road traf \201 c fatalities, 25 % of fatal work injuries, 30 % of drown- ings and 50 % of burn deaths. Alcohol is involv ed in 8 30 % of suicides, 8 60 % of homicides and most assaults. Suspicion is the key to de tecting alcohol problems. Units The number of \200\230units \200\231 (10mL of pure alcohol) is included on packaging . A bottle of wine contains 8 10U and a bottle of spirits 8 30U. Current advice is a \200 \230safe \200\231 limit of 21U/week (males) and 14U/week (females). Alcohol absorption, metabolism, and elimination Alcohol is absorbed from the small intestin e and to a lesser extent, the stomach. The rate of absorption depends on the nature of the drink and any associated food consumed. Alcohol is absorbed more slowly from dilute drinks (eg wine) compared with more concentrated forti \201 ed sherry or port. Alcohol is water s oluble, so distributes throughout the body. It is mostly metabolized in the liver by an enz ymatic process involving alcohol dehydrogenase, which converts it to acetaldehyde and then acetic acid. A relatively small amount of alcohol is excreted unchanged in the urine (and t o a lesser extent, in breath and sweat). Clearance of alcohol The rate of clearance of alco hol from the blood varies enormously between individuals, with typical quoted values of 10 \200\22320mg/dL/hr in most adults, although higher values occur in some chronic alcoholics. Assessing alcohol problems A history of alcohol consumption is notoriously unreliable when taken from heavy drinkers and chronic alcoholics, who may signi \201 cantly under- report the extent of their drinking and its effect upon their lives. The actual amount of alcohol consumed is less important than the consequences of drinking to the patient. Cover the foll owing areas: Biological GI upset/bleeding, withdrawal \201 ts, blackouts, peripheral neur opathy. Psychological Low mood, hallucinations, delusions, memory problems. Social Marital, work, driving, debt, criminality. Signi \201 cant features include compulsion to drink an d loss of control. The CAGE questionnaire \200 Have you ever felt you should Cut down your drinking? \200 Have people Annoyed you by criticizing your drinking? \200 Have you ever felt Guilty abou t your drinking? \200 Have you ever had a drink \201 rst-thing in the morning to steady your nerves or to get rid of a hangover (Eye-opener)? Any single, + ve answer is signi \201 cant and > 1 + ve answer is probably diagnostic of c hronic alcohol dependence. 623 ACUTE ALCOHOL INTOXICATION Acute alcohol intoxication Effects of intoxication Alcohol depresses the nervous system \200\224 initial euphoric effects are due to suppression of inhibition by the cerebral cort ex. Effects vary between indi- viduals and Table 14.5 is a very rough guide. Behavior, incl uding propen- sity to violence, is in \202 uenced by environment and social setting. Altho ugh death may occur at levels > 350mg/100mL, the risk of a harmful or fatal event increases at any level: especially road traf \201 c collisions, work and home accidents and assault s (including sexual assault). The current UK blood alcohol legal limit for driving is 80mg/ mL. Table 14.5 Effects of various concentrations of alcohol Blood alcohol concentration (mg/100mL = mg/dL) Effects 30 \200\22350 Measurable impairment of motor skills 50 \200\223100 Reduced inhibitions, \200\230excitant effect \200\231 100 \200\223150 Loss of co-ordination and control 150 \200\223200 \200\230Drunkenness \200\231, nausea, ataxia 200 \200\223350 Vomiting, stupor, possible coma 350 + Respiratory paralysis, possible death Alcohol intoxication is characterized by slurred speech, incoordination, unsteady gait, nys tagmus, lethargy, and facial \202 ushing. The differential diagnosis is extensive: head i njury, hypoglycaemia, post-ictal confusional states, hepatic encephalopathy, meningitis, en cephalitis, or intoxication with other drugs. In most patients these conditions can be excl uded by examination and simple investigations (although some not infrequently coexist with acute alcohol intoxication \200\224 especially head injury and hypoglycaemia). Management Aim to discharge conscious, ambulant patients who exhibit uncomplicated acute al cohol intoxication if accompanied by a responsible adult. Violent patients who appear intox icated require examination prior to escort from the ED by police. As a minimum, perform a b rief neurological examination, simple observations and BMG. Comatose patients are a medical emergency. Protect the airway and anticipate vomiting (recovery position may be useful). E xclude hypoglycaemia and other metabolic causes of coma. Exclude head or neck injury, and a dopt a low threshold for X-ray and/or CT scanning. Close observation is mandatory. Alcohol- induced hypoglycaemia particularly affects chronic alcoholics and children. It also occurs in binge drinkers who present with alcoholic ketoacidosis. Hypoglycaemia can occur during i ntoxication and up to 24hr after. In children, \201 ts may result. Coagulation disorders often occur in chronic alcoholics with liver damage. Consider this in patients presenting w ith GI hemorrhage or head injury. 624 CHAPTER 14 Psychiatry Alcohol withdrawal \200\230Simple \200\231 alcohol withdrawal Uncomplicated alcohol withdr awal is common, usually starting within 12hr of stopping (or reducing) alcohol intake. With drawal symptoms often commence before alcohol is completely cleared from the blood. Feature s include anxiety, restlessness, tremor, insomnia, sweating, tachycardia, and ataxia. Simpl e withdrawal can be managed on an outpatient or day patient basis. It may be appropriate to commence treatment in the ED for uncomplicated withdrawal (eg diazepam 5 \200\22310mg PO o r chlordiazepoxide 10 \200\22330mg), but continuing treatment should not be prescribed by E D staff. Inpatient detoxi \201 cation is indicated for those with a history of withdrawal seizures, delirium tremens or with withdrawal symptoms who are being admitted for other pro blems. The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) Score ass esses 10 clinical signs of withdrawal and may help to guide treatment ( www.agingincanada.c a/ CIWA.HTM ). Note: alcoholics admitted with \200\230simple \200\231 withdrawal may be th iamine de \201 cient, and need parenteral and/or oral thiamine. Delirium tremens Occurs in a small minority of alcoholics who undergo withdrawal and carrie s a signi \201 cant mortality. It typically starts > 48hr after stopping drinking. As well as \200\230simple \200\231 withdrawal, there may be signi \201 cant auto- nomic hyperact ivity, with tachycardia, hyper-re \202 exia, hypertension, fever, visual or tactile halluc inations, sinister delusions, disorientation, and confu- sion. Deaths occur from arrhythmia s (secondary to acidosis, electrolyte disturbance, or alcohol-related cardiomyopathy), infe ction, \201 ts or cardio- vascular collapse. Monitor closely, check BMG, give IV diazepam as appro- priate (especially for \201 ts) and refer to the medical team/HDU. Alcohol withdrawal \201 ts These typically comprise self-limiting grand mal seizures whic h occur hours or days after the last alcoholic drink. Check BMG and treat \201 ts in a st andard fashion ( b Seizures and status epilepticus, p.149). Examine carefully for possible head injury. Alcoholic ketoacidosis This can occur when an alcoholic stops drinking, vomits repeatedly a nd does not eat. Ketoacidosis develops from fatty acid breakdown, compli- cated by dehydrat ion from vomiting. The patient usually presents 1 \200\2232 days after the last binge with vomiting, signs of chronic alcohol abuse and a high anion gap metabolic acidosis. Arterial blood gas (ABG) may reveal d p CO 2 , d HCO 3 \200\223 , normal p O 2 . pH is variable bec ause metabolic acidosis may be altered by metabolic alkalosis from vomiting and possibly re spi- ratory alkalosis. Plasma ethanol is low or absent. Differential diagnosis includes sal icylate, methanol and ethylene glycol poisoning ( b p.203). Give IV 0.9 % saline with 5 % g lucose and thiamine supplementation, whilst monitoring U&E, glucose. Refer to the medical t eam and consider HDU/ICU. 625 HELP FOR ALCOHOLICS Alcohol-related brain injury Wernicke Korsakoff syndrome develops in problem drinkers who a re thiamine de \201 cient. Autopsy analysis suggests that the syndrome may occur in as man y as 12.5 % of chronic alcohol misusers. A presumptive diagnosis of the Wernicke Korsakoff syndrome may be made in patients with a history of alcohol misuse and one or more of the fo llowing unexplained symptoms: ataxia, ophthalmoplegia, nystagmus, confusion, memory distur- bance, reduced conscious level, hypotension, and/or hypothermia. Wernicke \200\231s encephalopathy This is characterized by degenerative changes surrounding the third ventricle and aqueduct, particularly the mammillary bodies. It presents with an acute confusional state, nystagmus, ophthalmoplegia, ataxia, and polyneuropathy. Ataxia typ ically affects the trunk and lower extremities. Clinical abnormalities may develop acutely or evolve over several days. Initial treatment involves parenteral thiamine (eg Pabrinex 10mL as an IV infusion in 100mL 0.9 % saline over 30min). Note that this may occasionally cause anaphylaxis, so ensure that resuscitation facilities are available. Subsequent treatm ent involves oral thiamine. Korsakoff \200\231s psychosis This is an amnesic state with profound retrograde and anterog rade amnesia, but relative preservation of other intellectual abilities. It typically devel ops after Wernicke \200\231s encephalopathy, but some patients develop a combined syndrome from the outset with memory loss, eye signs and unsteadiness but without confusion. Treat with parenteral thiamine and admission as for Wernicke \200\231s encephalopathy. Help for alcoholics The relatively regular contact between those with alcohol problems and EDs may be viewed as an opportunity to offer intervention. There is good evidence to sugges t that brief interventions may reduce alcohol consump- tion and the risk of physical harm. Consider the 1min Paddington Alcohol Test to help patients who present with alcohol-related problems ( http:// alcalc.oxfordjournals.org/cgi/reprint/44/3/284 ). The following organizations may help: Alcoholics Anonymous ( www.alcoholics-anonymous.org.uk ), plus local networks and telephone numbers. Al-Anon for relatives telephone number 020 7403 0888 (and websites www.al-anonuk.org.uk and www.al-anon.alateen.org ). 626 CHAPTER 14 Psychiatry Drug and substance abuse Drug users present to the ED at times of crisis (eg acute intoxica tion, overdose, withdrawal or other medical complications of drug use). Do not assume all d rug users present to the ED simply to obtain drugs. Find out about local addiction services and how referrals are made. Direct those seeking help with a drug problem to the appropria te services. Know local preferred drugs of abuse and the preferred methods of taking them. Find out what terminology is used locally for each substance. Do not supply drugs of depend ence to addicts. Prescriptions are carefully controlled by addiction services and pharmacis ts. Elaborate tales of lost or stolen drugs/prescriptions are invariably false. Manage painful conditions in drug addicts as for other patients. Do not withhold analgesia if in obvious pain. For minor complaints, simple analgesia is as effective as in non-drug u sers. Do not dismiss symptoms simply because the patient is a drug user. Even drug abusers get acute appendicitis and other common acute illnesses. Intoxication As with alcohol, mild cases require little intervention. Observation by a resp onsible adult or brie \202 y in a ward usually suf \201 ces. Discharge patients when ambu lant and fully orientated, having excluded serious problems. Glue and solvents Users may sm ell of substances or have them on their clothes or skin. There may be a perioral rash. Into xication produces euphoria, agitation or drowsiness, slurred speech, and unsteady gait. Ben zodiazepines and CNS depressants Mild intoxication is similar to that with alcohol. i intox ication produces nystagmus, diplopia, strabismus, hypotonia, clumsiness, and moderately dil ated pupils. Amphetamines, ecstasy, cocaine and mephedrone Produce hyperstim- ulation, rest lessness, pyrexia and sympathomimetic effects. Cocaine effects occur more rapidly. Severe c ases exhibit paranoia, violent behavior or seizures. Cocaine may also cause chest pain, arr hythmias or even MI. Ecstasy can cause an idiosyncratic reaction similar to malignant hyper thermia (see b Illicit drugs, p.214). Overdose Protect the airway, provide oxygen (O 2) as required and exclude hypogly- caemia o r serious injury in all cases. Opioid overdose is often inadvertent, either from use of unu sually pure drugs or after a period of abstinence (tolerance is d ). Characteristic signs a re coma with pinpoint pupils and respiratory depression (see b p.188). Pulmonary oedema, hy pothermia and rhabdomyolysis can occur. Hypoxia may cause dilated pupils. If opioid overdos e is suspected, give naloxone 0.4 \200\2230.8mg IV, repeated according to response. See b A ntidotes to poisons (b p.186) for further detail regarding treatment. Remember to ensure th at the patient is observed for at least 6h after the last dose of naloxone. Intentional ove rdose requires assessment of suicide risk ( b p.614) and mental capacity in case the patien t threatens to leave against advice. 627 DRUG AND SUBSTANCE ABUSE Skin complications SC drug injection ( \200\230skin popping \200\231) can cause cellulitis, abscesses, extensive skin necrosis, necrotizing fasciitis, tetanus, botulism and anthrax. Refer for formal exploration, drainage and follow-up by the surgical team for all but the m ost minor infections. Apparently \200\230simple \200\231 abscesses may extend deeply into muscle or form part of a false aneurysm! Needle fragments rarely require removal unless the y embolize (eg to the lungs). Anthrax in drug users After an outbreak of anthrax in heroin users in Scotland in 2010, Hea lth Protection Scotland ( www.hps.scot.nhs.uk ) advised doctors to suspect anthrax in a dru g user presenting with any of the following: \200 Severe soft tissue infection and/or sig ns of severe sepsis/meningitis. \200 Clinical features of inhalational anthrax ( b p.233) . \200 Respiratory symptoms + features of meningitis or intracranial bleeding. \200 GI symptoms (eg pain, bleeding, nausea, vomiting, diarrhea, ascites). Approach Get expert help early to advise on management (ICU, surgeons, micro- biology, Public Health, hospital infe ction team). Start IV antibiotics according to advice (eg combination of cipro \202 oxacin , clindamycin + peni- cillin or if there is soft tissue infection: cipro \202 oxacin, clin damycin, peni- cillin, \202 ucloxacillin + metronidazole). Experts will advise on whether to use anthrax immune globulin intravenous (human) antitoxin. Vascular complications IV injection ( \200\230mainlining \200\231) of drugs causes phlebiti s, DVT, and bacterial endocarditis. Chronic injectors may resort to neck or groin vessels ( the femoral artery being commonly damaged). Arterial injection can cause false aneurysms, \201 stulae, or peripheral emboli. Occasionally, IV drug users present with massive and de vastating blood loss from an injection site (particularly the groin): apply \201 rm press ure, resuscitate with IV \202 uids blood and call for the surgical team. Inadvertent arterial injection of poorly soluble preparations causes severe limb pain, skin pallor and mottling with paraesthesiae in the presence of palpable (often bounding) periph eral pulses. Diffuse soft tissue damage may result in compartment syndromes, rhabdomyolysis , renal failure, and irreversible limb damage necessitating amputation. Orthopedic complications Injecting drug users who present with acutely painful joints (espe cially hip joints) may have septic arthritis. Clinical and radiological evidence may be min imal, so adopt a high index of suspicion. Provide analgesia, take blood cultures, and FBC, and admit for joint aspiration and IV antibiotics. Drug withdrawal states Sometimes drug users present to hospital with overt evidence of drug ( alcohol) withdrawal. It can be dif \201 cult to judge whether the problem is due to drug intoxication, drug-related (eg stimulant induced psychosis, \200\230panic reaction \200\231), drug withdrawal, or to coexistent disease. Observe and monitor closely \200\224 treat symptomatically (eg with small doses of oral benzodiazepines as necessary) and refer to the medical team. 628 CHAPTER 14 Psychiatry Compulsory hospitalization Compulsory detention of patients in the UK requires the patient to be both: \200 Suffering from a mental disorder (mental illness or handicap). \200 Re quiring emergency hospital admission to protect the health or safety of the patient or for the protection of others. Emergency detention under mental health legislation does not allow treatment for psychiatri c illness. Emergency treatment of psychiatric or physical illness is carried out under comm on law . In this situation, there must be an immediate threat to life or serious danger to the patient or others, if treatment is not given. For this reason, mental health legislatio n cannot be used to impose emergency treatment without patient consent. Note that ED patien ts are not legally inpatients until they go to a ward. Detention of psychiatric emergencies in the ED England and Wales Section 2 is used most com monly in the ED. It requires recommendations from 2 doctors to be accepted by an approved s ocial worker and allows detention for up to 28 days for assessment and treatment. Scotland The Mental Health (Care and Treatment) (Scotland) Act 2003 came into effect in 200 5 \200\224 see www.nes-mha.scot.nhs.uk/ . Part 5 of the Act enables a fully registered med ical practitioner to grant an emergency detention certi \201 cate that authorizes managers of a hospital to detain someone for 72hr. Before granting an emergency detention certi \201 cate, the medical practitioner also needs to consult and gain the consent of a mental health of \201 cer, unless impracticable. The patient is then examined by an approved medi cal practitioner (psychiatrist), who if not satis \201 ed that the relevant criteria are m et, cancels the certi \201 cate. Northern Ireland Mental Health (Northern Ireland) Order 1986, Part II. Article 4 \200\224 Admission for assessment of mental disorder. \200 Requires 2 or 3 doc tors including the responsible medical of \201 cer (RMO) \200\224 in charge of patient \200\231s treatment. Application by nearest relative or an approved social worker. \200 Lasts 7 days, renewabl e up to 14 days. \200 Lasts until discharge by RMO board or nearest relative or until det ained under article 12. Section 136 (England) This allows a police of \201 cer to detain someone in a public place when he/ she appears to be mentally disordered and is causing a disturbance. The police of \201 cer \200\231s responsibility is to take the detained person to a \200\230place of s afety \200\231 (usually a police station or psychiatric ward) where he/she is assessed by a psychiatrist and approved social worker. The Mental Health Act (Scotland) 2003 provides police of \201 cers in Scotland with simila r powers: a police constable may remove a person to a place of safety from a public place, if a mental disorder is suspected and it is also suspected that the person needs immediate care and treatment. 629 MENTAL CAPACITY ACT Mental Capacity Act The Mental Capacity Act 2005 (MCA) offers a comprehensive framework for decision-making on behalf of adults aged > 16 years lacking capacity to make decisions on their own behalf. It only applies in England and Wales. De \201 ning capacity A person lacks capacity if, when a decision needs to be made, they a re unable to make or communicate the decision because of an \200\230impairment or disturba nce of the mind or brain \200\231. There is a 2-stage test of capacity: \200 Is there an impairment of, or disturbance in the functioning of, the person \200\231s mind or brain? If so, Is the impairment or disturbance suf \201 cient that the person lacks the capacity to make that particular decision? Five statutory principles \200 Capacity must be assumed unless it is established to be la cking. \200 A person is not being treated as unable to make a decision unless all practic able steps to help him do so have been taken without success. \200 A person should not be treated as unable to make a decision merely because he makes an unwise decision. A decision made, or action performed, for or on behalf of a person who lacks capacity must be taken in his/her best interests. Before a decision is made or an action performed, consideration must be given to whether th e purpose for which it is needed can be as effec- tively achieved in a way that is less res trictive of the person \200\231s rights and freedom of action. Assessment of capacity A person lacks capacity if he/she fails: \200 To understand the in formation relevant to the decision. \200 To retain the information relevant to the decisi on. \200 To use or weigh the information. \200 To communicate the decision (by any mean s). Admission and treatment Patients can be admitted and treated under the Mental Capacity Act 2005 only if 6 qualifying safeguards are met: \200 The person is at least 18 years old. \200 The person has a mental disorder. \200 The person lacks capacity to decide whether to be in hospital or care home for the proposed treatment or care. The proposed deprivation of liberty is in the person \200\231s best interests and it is necessary and proportionate response to the risk of harm. The person is not subject, or potentially subject, to speci \201 ed provisions of the Mental Health Act in a way that makes them ineligible. There is no advance decision, or decision of an attorney or deputy which makes the proposed deprivation of liberty impossible. In other circumstances, consider using the Mental Health Act 1983 to admit mentally disorde red patient who lack capacity to consent. 630 Chapter 15 Chapter 00 Pediatric emergencies Pediatric problems also covered elsewhere in this book: b Consent 28 b Poisoning 179 b Incu bation periods of infectious diseases 220 b Childhood infectious diseases 222 b Meningitis 224 b Gastroenteritis/food poisoning 226 b Infestations 230 b Analgesia in speci \201 c si tuations 280 b Nasal diamorphine 281 b Local anesthesia in children 287 b Sedation 309 b In structions after minor head injury 367 b Tetanus prophylaxis 410 b Earache 550 b Sore throa t 554 The pediatric environment Primary assessment and resuscitation of the sick child Standard i mmunization schedule Venous access and venepuncture Intra-osseous infusion Resuscitation of the newborn Cardiopulmonary resuscitation of the newborn Pediatric basic life support Chok ing from a foreign body Anaphylaxis in children Pediatric advanced life support Pediatric a dvanced life support notes Children with abnormal heart rates or rhythms Sudden infant deat h syndrome (SIDS) Problems of neonates and infants Skin problems in infants The febrile chi ld Purpuric rashes 632 634 636 638 640 642 644 646 648 650 652 654 656 658 660 662 663 664 631 Chapter 15 Pediatric emergencies Meningococcal disease How to perform a lumbar puncture Skin lesions in multisystem disease Pediatric ENT problems Stridor: upper respiratory infections Severe acute asthma in childre n Acute bronchiolitis Whooping coughND TBND and cystic \201 brosis Pneumonia Fits, febril e convulsions, and funny turns Status epilepticus Diabetic ketoacidosis Urinary tract infec tion (UTI) Renal failure Haematuria Poisoning in children Prevention of pediatric poisoning Abdominal pain in children Inguinal and scrotal swellings Foreskin problems and zip entrap ment The limping child The painful hip Osteochondritis Major pediatric trauma Injury preven tion Resuscitation of the injured child Considerations in pediatric trauma Head injuries in children Pediatric fractures and dislocations Approach to limb injuries in children Pediat ric upper limb injuries Pediatric lower limb injuries Child abuse Presentation of child abu se Management of child abuse