Symptoms Ectopic pregnancy may present with sudden severe lower abdominal pain with collaps e or fainting, and vaginal bleeding. There is usually (but not always) a history of amenorr hoea (often 8 weeks). Hemorrhage may cause shoulder tip pain (from blood irritating the dia phragm) and features of hypovolaemia. Nausea and vomiting are common. Many patients have more chronic symptoms, with recurrent abdominal pain and slight irregula r vaginal bleeding, which may be fresh or dark (like \200\230prune juice \200\231). Pain m ay have continued for > 1week before presentation, occasionally as long as 4 weeks. The pai n may be worse on defecation. Some patients have no vaginal bleeding. Enquire about symptoms of pregnancy (eg breast tenderness) and possible risk factors for ec topic pregnancy. 587 ECTOPIC PREGNANCY Signs Look for hypovolaemic shock. If present, volume replacement must accompany full asses sment. Abdominal tenderness is variable, ranging from mild to severe with peritonism. Culle n \200\231s sign (discolouration around the umbilicus) is of historical interest only. Bima nual vaginal examination reveals tender adnexa and sometimes a mass, but may be better defe rred to a specialist (risk of i bleeding). Speculum inspection usually shows vaginal blood. Investigation Must not delay resuscitation and referral. Pregnancy test is almost always + ve, but serum B-HCG levels are lower than expected for normal pregnancy. Transabdominal USS is useful if it demonstrates an intrauterine pregnancy, free \202 uid in the pouch of Douglas and/or an adnexal mass. Frequently it is inconclusive. Transvaginal USS may be better. Differential diagnosis \200 Threatened abortion : bleeding is usually more severe ( b p.5 84). \200 Ruptured corpus luteum cyst : the corpus luteum supports pregnancy for the \201 rst 6 \200\2238 weeks. Rupture causes sudden peritoneal irritation, but rarely bleeds signi \201 cantly. PID ( b p.573): Note that ectopic pregnancy can cause mild pyrexia and a raised WCC, which may easily be misinterpreted as evidence of pelvic infection. Trophoblastic disease ( b Vaginal bleeding in later pregnancy, p.588). Treatment Give O 2 , insert two large (12 or 14G) cannulae, cross-match 6U of blood, reques t Rhesus status. Resuscitate initially with crystalloid IV \202 uids as necessary. If sus pected, refer urgently to the gynecology team since sudden deterioration may occur. Signi \201 cant hemorrhage requires urgent surgery. Alert the anesthetist and theater team early. Check Rhesus and antibody status: anti-D immunoglobulin may be needed ( b p.582). 588 CHAPTER 13 Obstetrics and gynecology Vaginal bleeding in later pregnancy Gestational trophoblastic disease Occasionally, a ferti lized ovum may form abnormal trophoblastic tissue, but no fetus. The pathological spectrum ranges from benign hydatidiform mole to invasive choriocarcinoma. Choriocarcinoma is relati vely rare, affecting 8 1 in 40,000 pregnancies. Presentation Usually vaginal bleeding at 12 \200\22316 weeks, with passage of tissue, which may resemble frogspawn. Often accompanying abdominal pain and sometimes pre-eclampsia or eclampsia. The uterus may be much larger tha n expected for dates. DIC may occur. Investigations USS shows \200\230snowstorm \200\231 and no fetus. Serum HCG is grossly i . Management Obtain venous access, serum HCG, FBC, group and save, IV \202 uids/resuscitati on, and refer. Antepartum hemorrhage Bleeding after 20 weeks occurs in 2.5 % of pregnancies. Abruptio plac entae and placenta praevia are most likely causes, although other cervical or vaginal lesio ns may be responsible. Abruptio placentae Premature separation of the normally situated placenta affects 8 1 % of pregnancies. It causes hemorrhage which may risk the fetus, depending on the extent of plac ental involvement, and rapidity of separation. Risk factors Pre-eclampsia, previous abrupti on, trauma ( b p.594), smoking, i parity, cocaine. Presentation There is usually some vagin al bleeding ( \200\230revealed hemorrhage \200\231), but occasionally bleeding is limited t o the con \201 nes of the uterus ( \200\230concealed hemorrhage \200\231). In either case, there may be much more utero-placental bleeding than is immediately apparent. There may be abdominal pain and tenderness or back pain. Abruptio placentae may precipitate labor. A la rge bleed can cause DIC or absent fetal heart sounds. Placenta praevia The placenta is situated wholly or partly over the lower uterine segment a nd cervical os. Risk factors Mother aged > 35 years, high parity, previous placenta praevia, twins, uterine abnormalities (including previous Caesarian section). Presentation Most present with bright red painless vaginal bleeding in the third trimester. 15 % present in labor. If placenta praevia is a possibility, do not perform digital or speculum vaginal examinatio n. Vasa praevia Rarely, an abnormal fetal blood vessel may be attached to the membranes over t he internal os. Hemorrhage may cause fetal exsanguination, usually during labor. 589 VAGINAL BLEEDING IN LATER PREGNANCY Management of antepartum hemorrhage \200 Call an obstetrician immediately. \200 Give O 2 . \200 Obtain venous access (2 large bore cannulae) and resuscitate with IV \202 uids as necessary. Send U&E, FBC, blood glucose, cross-match, Rhesus and antibody status, Kleihauer test, clotting screen. \200 Monitor the fetus (cardiotocography). \200 USS locates the placenta, demonstrates the fetus and may show concealed hemorrhage. Give anti-D immunoglobulin as advised by Blood Transfusion Service if Rh \200\223ve ( b p.582). 590 CHAPTER 13 Obstetrics and gynecology Abdominal pain in pregnancy Approach Attempting to deduce the cause of abdominal pain can o rdinarily be quite dif \201 cult: in pregnancy it is even more so. Some possible underlyin g diseases may be causing unseen fetal distress and can produce rapid maternal deterioratio n. Therefore, triage ahead, contact the obstetrician, and resuscitate vigorously. Initial i nvestigations usually include BMG, uri- nalysis, blood tests, and USS. Vaginal bleeding acc ompanying abdominal pain implies a gynecological or obstetric problem. Remember, however, t hat the reverse is not necessarily true: ruptured ectopic pregnancy and concealed hemorrhag e in abruptio placentae may present without vaginal bleeding. In later pregnancy, even if t here is doubt as to whether the principal problem is obstetric or not, involve the obstetri cian at an early stage. Pregnancy related causes of abdominal pain The following are considered elsewhere: \200 E ctopic pregnancy ( b p.586). \200 \200\230Red degeneration \200\231 of a \201 broid ( b Uterine problems, p.572). \200 Gestational trophoblastic disease ( b Vaginal bleeding i n later preg- nancy, p.588). Abruptio placentae ( b p.588). \200 Onset of labor ( b Emergency normal delivery, p.578). Torsion, rupture, or hemorrhage into an ovarian cyst This may involve the corpus luteum of pregnancy. Sudden onset lower abdominal pain results. USS may demonstrate the problem. Acute polyhydramnios Excessive amniotic \202 uid may complicate pregnancy involving uni-o vular twins. Pain and vomiting is accompanied by a large abdomen for gestation and an unusu ally mobile fetus. Pre-eclampsia Abdominal pain (particularly right upper quadrant pain) in pregnancy may re \202 ect pre-eclampsia (see b p.592). Check BP and urinalysis and refer urgently. 591 ABDOMINAL PAIN IN PREGNANCY Non-obstetric causes of abdominal pain Urinary tract infection UTI is relatively common in pregnancy due to urinary stasis. Women are at particular risk if they have had previous UTI . Abdominal/loin pain and pyrexia with rigors indicate acute pyelonephritis. Send MSU, FBC, and blood cultures, and refer for IV antibiotics. Treat patients with asymptomatic UTI or cystitis without evidence of pyelonephritis with oral antibiotics (eg amoxicillin 250mg PO tds or a cephalosporin) and arrange GP follow-up when the MSU result will be available. Whe n prescribing antibiotics in pregnancy, take care to avoid those drugs which are contra- in dicated (eg trimethoprim, tetracyclines \200\224 see BNF ). Acute appendicitis Presentation in early pregnancy may be as classically described, but can be confused with ectopic pregnancy or rupture/torsion of an ovarian cyst. In later pregnan cy, the point of maximal tenderness in acute appendicitis rises towards the right hypochond rium. Check BMG, serum amylase, and urinalysis. Give analgesia and refer if suspected. Gallstones Pain from gallstones not infrequently presents for the \201 rst time in preg- nancy. The presentation of biliary colic and cholecystitis is similar to that in the non-pr egnant patient ( b Biliary tract problems, p.510). USS reveals stones and associated pathol ogy. Give analgesia and refer: if possible, the patient will be treated conservatively. Acute pancreatitis This is usually related to gallstones. There is a signi \201 cant risk to mother and fetus. Presentation and treatment are as described in b p.508. Perforated pep tic ulcer If suspected, obtain erect CXR with lead shield for the fetus. Resuscitate and re fer ( b p.511). Intestinal obstruction Often follows adhesions from previous surgery. The d iagnosis may not be immediately obvious: pain, vomiting, and constipation may be initially attributed to pregnancy. These symptoms, together with abdominal tenderness and high pitche d bowel sounds suggest the diagnosis. An erect abdominal X-ray will con \201 rm it, but th is should only be requested by a specialist. 592 CHAPTER 13 Obstetrics and gynecology Medical complications of pregnancy Pre-eclampsia and eclampsia This poorly understood vasos pastic uteroplacental disorder affects 7 % of pregnancies. It results in widespread systemi c disturbance involving the liver, kidneys, coagulation, and cardiovascular systems. Placen tal infarcts may occur and compromise the fetus. Pre-eclampsia 2 or more of: hypertension ( > 140/90), proteinuria and oedema. Variant prese ntation: haemolysis, elevated LFTs, low platelets (HELLP syndrome) particularly affects mul tigravida. Progression to eclampsia is heralded by: confusion, headache, tremor, twitching, i re \202 exes. Visual disturbance and/or abdominal pain may occur. Eclampsia The onset of \201 ts after 20 weeks (or \201 ts in association with pre-eclampsia). Maternal mortality is 2 % , perinatal mortality 15 % . Management See www.rcog.org.uk \200 Refer all patients with BP > 140/90, or proteinuria a nd oedema. \200 Obtain FBC, uric acid, U&E, LFTs, clotting screen, ECG, fetal monitoring. Restrict \202 uids to a total of 80mL/hr or 1mL/kg/hr (because of the risk of pulmonary oedema). If there is evidence of impending eclampsia or the patient starts to \201 t: call the obs tetrician and anesthetist, check BMG, control airway, consider left lateral position, give O 2 and 4g magnesium sulfate slowly IV over 10min, followed by a maintenance magnesium sulf ate 1g/h IVI. Treat recurrent \201 ts with a further 2g magnesium sulfate IV over 10min. Follow local advice regarding control of hypertension (eg labetalol 10mg slow IV bolus, fol lowed by an IVI starting at 1 \200\2232mg/min, i as required). \200 Urgent delivery is a priority in eclampsia, both for mother and fetus. Disseminated intravascular coagulation DIC may complicate a variety of obstetric problems: abruptio placentae, intrauterine death, missed abortion, amniotic \202 uid embolism, ecla mpsia, sepsis, trophoblastic disease. Clinical picture Widespread hemorrhage and microvascular occlusion. Obtain FBC, cross-match, clotting screen, \201 brin degradation products, \201 brinogen , U&E, and LFTs. Treatment Resuscitate with O 2 , IV \202 uids (according to CVP), blood transfusion, and FFP. Refer urgently and consider urgent delivery and treatment of underlying disease. 593 MEDICAL COMPLICATIONS OF PREGNANCY Diabetes mellitus Pregnancy encourages hyperglycaemia. IDDM in pregnancy may be more dif \201 cult to control and is associated with an i insulin requirement. DKA occurs relatively easily ( b Hyperglycaemic crises, p.152). Thromboembolic disease Pregnancy carries an i risk and is a signi \201 cant cause of mater nal mortality. The exact risk in each trimester is as yet unclear, as little research has i nvolved pregnant women. However, it would seem that the more gravid the woman, the greater the risk of DVT and PE. Caesarian section, pre- vious DVT/PE, a family history and bed rest all increase the risk. Clinical probability scoring for DVT or PE is dif \201 cult as all derived scores excluded pregnant women. Therefore, pregnant women should have imaging, rather than D-dimer and cli nical probability assessment. USS is the safest initial investigation for DVT. Remember that to exclude DVT with ultrasou nd requires either one normal complete scan (calf, popliteal fossa and thigh) or two normal thigh and popliteal scans, one week apart ( b p.118). Pulmonary embolism presents with pai n or dyspnoea ( b p.120). Unfortunately, these are not infrequent symptoms during pregnancy . A normal SpO 2 in air will not exclude PE. Always request a CXR as this will reveal other life threatening causes (pneumothorax) and is required for VQ reporting. Investigation for PE starts with bilateral leg ultrasound scans (no risk to fetus). If these are normal, the patient should have a VQ scan (b Pulmonary embolism, p.120). If the VQ scan cannot diagnos e or exclude PE, arrange a CT scan . During investigation for DVT or PE it is standard practice to commence thrombosis treatment with low molecular weight heparin (LMWH). Thrombolysis has been used successfully in peri- arrest pregnant women with a clear clinical picture of PE. If the patient is not peri-arres t, always endeavor to obtain diagnostic imaging. Warfarin is teratogenic in the \201 rst trimester and may cause fetal or placental bleedi ng in later pregnancy, so avoid it in pregnancy. Other problems Thyrotoxicosis presents not infrequently in pregnancy. Pre-existing heart di sease worsens as blood volume and cardiac output i : involve a specialist early. Although rare, consider aortic dissection in any pregnant patient with unexplained, severe chest, back or neck pain ( b p.92). 594 CHAPTER 13 Obstetrics and gynecology Trauma in pregnancy Background Principal causes are similar to those in the non-pregnant: r oad traf \201 c colli- sions, falls and assaults. Contrary to popular opinion, the use of seat belts does d risk of serious injury in pregnancy. The \200\230lap \200\231 belt shoul d lie over the anterior superior iliac spines. Anatomical considerations The following are worthy of consideration: \200 As the uterus e nlarges it rises out of the pelvis with the bladder \200\224 both are at i risk of injury. The size of the uterus and stretching of the peritoneum make abdomi- nal assessment dif \201 cult. The bony pelvis is less prone to fracture, but retroperitoneal haemor- rhage may be torrential due to i vascularity. The pregnant uterus may obstruct the inferior vena cava, causing supine hypotension and increased bleeding from lower limb wounds. The diaphragm is higher in pregnancy. \200 The pituitary doubles in size and is at risk o f infarction in untreated hypovolaemic shock. Physiological considerations Pregnancy is associated with dramatic changes in physiology: \200 Pregnant patients may tolerate up to 35 % loss of blood volume before manifesting cla ssic signs of hypovolaemic shock, largely at the risk of uteroplacental circulation. The d functional residual capacity and i O 2 requirement result in hypoxia developing more quickly. There is an i risk of regurgitation of gastric contents. \200 Coagulation may be deranged or rapidly become so. Injuries to the uterus, placenta, and fetus Fetal injury Both blunt and penetrating trauma may damage the fetus. It is, however, more likely to suffer as a result of maternal hypoxia /hypovol- aemia or placental abruption. Placental abruption Deceleration forces in blunt trauma may shear the inelastic placenta fr om the elastic uterus. Hemorrhage (maternal and fetal) may be signi \201 cant and result i n DIC. This may present with vaginal bleeding (much may be concealed internally), uterine t enderness, or fetal distress. Uterine rupture This is relatively uncommon. Major rupture causes severe bleeding. The uter us and fetus may be felt separately. Amniotic \202 uid embolism Rare and carries a poor prognosis. Presents with sudden collap se, dyspnoea, d BP, \201 tting, and bleeding (from DIC). 595 TRAUMA IN PREGNANCY Approach to the injured pregnant patient Follow that outlined in b Major trauma, p.319, wit h the additional speci \201 c points. History Determine gestation and any problems in this and previous pregnancies. Examination \200 Involve an obstetrician early: examine vagina for bleeding or rupture of membranes. Palpate for fundal height (mark skin), abdominal tenderness, uterine contractions. Listen for fetal heart sounds and rate using a fetal stethoscope (Pinard) or Doppler probe. Remember that head injury may mimic eclampsia and vise-versa. Investigation \200 Check BM G, coagulation screen, Rhesus/antibody status, and Kleihauer test. Consider CVP monitoring (remembering the CVP is lower in preg- nancy). Monitor fetal heart (cardiotocograph) \200\224 the rate should be 120 \200\223160/ min. USS investigates fetal viability, placental injury, gestational age, and free peritoneal \202 uid. Do not withold essential X-rays, but do consider early USS to look for free intra-abdominal \202 uid and fetal viability. Seek senior advice. Remember that the greatest risks from X-rays to the fetus are in early pregnancy. In later pregnancy, risks to the fetus may be o utweighed by failure to identify injuries by not obtaining X-rays. DPL has been largely superceded by USS (FAST scan) \200\224 but if indicated, use a supra-umbilical open approach (see b p.347). Treatment \200 Give O 2 and summon senior obstetric, ICU, and surgical help early. \200 If chest drains are required insert 1 \200\2232 intercostal spaces higher than usual. Decompress the inferior vena cava by manually displacing the uterus to the left or by using a 15 right lateral (Cardiff) wedge, or if neck injury has been excluded, by nursing in left lateral position. \200 Treat \202 uid losses with aggressive IV \202 uid replace ment. \200 An NG tube d risk of regurgitation and aspiration. \200 Remember tetanus pro phylaxis ( b p.410). \200 Consider anti-D immunoglobulin if the patient is Rh \200\223ve . \200 Even if there is no overt maternal injury refer for fetal monitoring for 4hr. Abdominal tenderness, hypovolaemia or fetal distress may require urgent laparotomy. If the patient has a cardiac arrest, perform emergency Caesarian section if the patient is > 24wks pregnant and 5mins has elapsed without output (see b p.596). 596 CHAPTER 13 Obstetrics and gynecology Cardiac arrest in pregnancy Rate Estimated in late pregnancy at 7 1 in 30,000. Causes strok e, PE, uteroplacental hemorrhage, amniotic \202 uid embolism, eclamptic \201 ts and hem orrhage, anesthetic problems, and drug reactions, underlying heart disease. Ischaemic heart disease is rarely implicated: the underlying rhythm is more commonly pulseless electrical activity than ventricular \201 brillation. Unfortunately, this is re \202 ected in the p oor prognosis. Remember the following physiological factors \200 The airway is dif \201 cult to control (large breasts, full dentition, neck oedema and obesity). Ventilation may be dif \201 cul t and intubation technically challenging. i aspiration risk ( d lower oesophageal pressure, i intragastric pressure) therefore securing de \201 nitive airway early is essential. i O 2 requirements in pregnancy, yet harder to ventilate ( d chest compliance). Chest compression is awkward ( \202 ared ribs, raised diaphragm, obesity, breast hypertrophy). Gravid uterus compresses inferior vena cava diminishing venous return. \200 There are 2 p atients: mother and fetus. Approach to resuscitation Follow Resuscitation guidelines for managing adult cardiac arrest ( b p.46). The special situation of pregnancy means some additional points apply. If there is advanced warning, think ahead. In addition to the usual team needed for airway control, IV access and chest compressions, organize: \200 An anesthetist for the airway, an obste trician to perform a Caesarian section and a pediatrician to resuscitate the baby. The neonatal resuscitation equipment (overhead warmer, suction, airway equipment and oxygen). A member of staff to apply cricoid pressure at the beginning of resuscitation and until the airway is secured. A member of staff to manually displace the uterus to the left until a left lateral tilt has been established with a Cardiff wedge. It may take time for help to arrive and there may be no warning prior to patient arrival. I n the meantime, proceed as follows: \200 Call the obstetrician, pediatrician, and ED cons ultant immediately. \200 Apply cricoid pressure (Sellick maneuver) at the beginning of resuscitation and until the airway is secured. Aim to secure the airway with a cuffed tracheal tube at an early stage. \200 Decompress t he inferior vena cava by either manual displacement of the uterus to the left, or the use o f sandbags or a special 15 right lateral ( \200\230Cardiff \200\231) wedge. Consider and treat the cause (eg remember that hypovolaemic shock from unseen hemorrhage ma y respond to a large IV \202 uid challenge). \200 If there is no return of spontaneous circulation within 5min perform a Caesarian section (providing the patient is > 24 weeks pregnant). 597 CARDIAC ARREST IN PREGNANCY Emergency Caesarian section Rationale After several minutes of maternal cardiac arrest the best chance of survival for the fetus is to be removed from the now hostile hypoxic environ ment of the uterus. Caesarian section also bene \201 ts the mother by decompressing the in ferior vena cava, resulting in i venous return. Procedure Continue closed chest compression and ventilation. Make a midline skin incision from pubic symphysis to epigastrium. Incise the underlying uterus vertically, starting 6cm above the bladder peritoneal re \202 ection . Continue the uterine incision upwards to the fundus, through an anteriorly placed placent a if necessary. Speed is essential. Deliver the baby, holding it head down and below the le vel of the mother \200\231s abdomen. Clamp and cut the umbilical cord. Resuscitate the baby ( b p.642). 598 CHAPTER 13 Obstetrics and gynecology Post-partum problems Physiology of the puerperium Within 24hr of delivery uterine involutio n results in the fundus being level with the umbilicus. By 2 weeks the uterus should be imp alpable. Uterine discharge ( \200\230lochia \200\231) gradually d , but may last up to 6 we eks. An initially bloody discharge becomes yellow within 2 weeks. The external cervical os gradually closes so that after 1 week it no longer accepts a \201 nger. Speculum examinat ion will now reveal the typical parous os (see Fig. 13.4 ). Post-partum hemorrhage Primary Hemorrhage > 500mL in the \201 rst 24hr is often related t o retained placenta/clots. This, together with uterine inversion and amniotic \202 uid em bolism are principally problems of the labor ward. Secondary Excessive fresh vaginal bleeding between 1 day and 6 weeks after a delivery affec ts 8 1 % pregnancies. The most common cause is retained products of conception: uterine inv olution may be incomplete and USS may reveal the retained products. Other causes include in trauterine infection (see below), genital tract trauma, trophoblastic disease. Resuscitate appropriately for blood loss and refer. Severe bleeding may respond to IV oxytocin. Pyrexia Treat according to the underlying cause, which include the following: \200 Pelvic infection (see below). \200 UTI. \200 Mastitis. \200 Chest infection. \200 DVT or PE. \200 Illness apparently unrelated to pregnancy/delivery. Pelvic infection Involves a signi \201 cant threat: may be complicated by septicaemia, nec ro- tizing fasciitis, DIC or septic PE. There is an i risk with: surgical proce- dures in l abor, prolonged membrane rupture, internal fetal monitoring, and repeated examinations. Features Uterine tenderness and subinvolution, pyrexia, offensive lochia, peritonitis. Send Vaginal swabs for culture, FBC, group and save, clotting screen and blood cultures. Resuscitate with O 2 and IV \202 uids and refer. For septic shock, follow severe sepsis g uidelines, give IV co-amoxiclav (1.2g) and IV metronidazole (500mg), monitor CVP, consider inotropes and ventilation. Infected episiotomy wound Refer to obstetrician. 599 POST-PARTUM PROBLEMS Mastitis and breast abscess Mastitis is commonly due to Staph . or Strep . Send milk for cu lture and commence oral antibiotics (eg co-amoxiclav). Instruct patient to express and disc ard milk from the affected breast, but to continue breast-feeding from the other. Arrange G P follow-up. Refer patients with abscesses for surgical drainage by incision or the now preferred aspira tion. Psychiatric illness Rapid hormonal swings are responsible for elation being frequently repl aced by tearfulness and anxiety ( \200\230fourth day blues \200\231). Less commonly (0.5 % pregnancies) puerperal psychosis occurs. Those with a previous psy- chotic illness are at p articular risk. Exclude sepsis and refer for psychiatric help. The patient may need to be c ompulsorily detained ( b Compulsory hospitalization, p.628). Thromboembolic disease A major cause of maternal mortality throughout pregnancy and the pue rperium. Adopt a high index of suspicion and refer for investigation ( b Pulmonary embolus, p.120). Nulliparous Multiparous Fig. 13.4 Appearance of the cervical os. This page intentionally left blank 601 Chapter 14 Psychiatry Approach to psychiatric problems Glossary of psychiatric terms The psychiatric interview Me ntal state examination The aggressive patient: background Safe consultations with potential ly violent patients Managing aggression Emergency sedation of a violent patient Deliberate self-harm Assessment of suicide risk Mental health assessment issues Depression Mania Schiz ophrenia Complications of psychiatric drugs Munchausen \200\231s syndrome Medically unexpla ined symptoms Alcohol abuse Acute alcohol intoxication Alcohol withdrawal Alcohol-related b rain injury Help for alcoholics Drug and substance abuse Compulsory hospitalization Mental Capacity Act 602 603 604 606 608 609 610 611 612 614 615 616 617 618 619 620 621 622 623 624 625 625 626 628 629 602 CHAPTER 14 Psychiatry Approach to psychiatric problems Psychiatric presentations comprise 8 1 \200\2232 % of ED n ew attendances. These patients are sometimes considered unwelcome because they are seen as complex, heavy consumers of staff time and energy, and not infrequently exhibit aggressive and/or disturbed behavior. A careful systematic approach to patients presenting with psychi atric emergencies produces an accurate diagnosis in most cases. If this is not possible, th e informa- tion gained will at least assist referral to the appropriate service, allowing m anagement of the problem. Liaison psychiatry service Many EDs have close links with liaison psychiatrists and special ist psychi- atric nurses. These individuals are used to managing a variety of psychiatric p roblems, including overdose and deliberate self-harm. In an emergency situation, they can a ct as an important source of advice. Potential points of con \202 ict The ED is not an ideal environment for the assessment of potential psychiatric illness. Remember the following: \200 The vast majority of aggressi ve, violent or bizarrely behaving patients in the ED are not suffering from a formal psychi atric illness. Many require the police, rather than psychiatric services. Admission is not mandatory simply because a psychiatric illness has been diagnosed. The presence of alcohol or drug intoxication makes any assessment of mental state very dif \201 cult and in many cases impossible \200\224 do not assume that this in itself re \202 ects an acute psychiatric problem. Acute alcohol withdrawal is a medical emergency with a signi \201 cant mortality \200\224 refers to the medical team, not acutely to the psychiatric service. Acute confusional states are usually organic rather than psychiatric in origin \200\223 investigate with this in mind. An emergency Section form must be signed by the examining doctor, but this does not have to be a psychiatrist. Similarly, psychiatric staff within the ED need to consider the following: \200 EDs are u nder pressure to manage large numbers of patients in a timely fashion, so it may be dif \201 cult for ED staff to spend large amounts of time with any single patient. Lack of appropriate interview facilities may make it necessary to compromise patient privacy rather than the safety of staff. A psychiatric referral can be appropriate in a patient who has is a signi \201 cant psychi atric history consumed alcohol, ( \200\230Dual Diagnosis \200\231). if there General approach to psychiatric problems Adopt the same approach of history taking and exam ination as with other general medical problems. Do not dismiss psychiatric patients as \200\230mad, therefore the psychiatrist can sort them out \200\231 \200\224 this can resul t in misdiagnosis and inappropriate referral. 603 GLOSSARY OF PSYCHIATRIC TERMS Glossary of psychiatric terms Concrete thinking Impairment of abstract, or symbolic thinkin g (eg interpretation of proverbs, explanation of similarities). Delirium An organic syndrom e characterized by rapid onset global disturbance of cognition, and disturbed consciousness . Delusion A \201 rm, usually false, belief unshakeable by logical argument or contrary e xperiences and which is out of keeping with the patient \200\231s social or cultural norms. Flight of ideas Thoughts rapidly cycle linked by chains of ideas or verbal associations or sounds resulting in disjointed, or in extreme cases, incomprehensible speech. Hallucinatio n A false perception not due to a sensory distortion or misinterpretation, but which occurs at the same time as real perceptions. Hallucinations can occur in each of the sensory moda lities. Auditory hallucinations are most commonly associated with psychiatric illness. Visu al and other hallucinatory phenomena suggest organic etiology. Ideas of reference A feeling that others are talking about or looking at the patient for some reason. Insight is usuall y retained, which is not the case in delusions of reference. Obsession Recurrent, persisten t, and intrusive thoughts, impulses or mental images that the individual usually tries to r esist, \201 nds unpleasant and recognizes as senseless. Passivity An experience of being under external control either physically, emotionally or intellectually. Suggests schizophr enia. Perseveration Repetition of an idea, thought, speech or an action beyond the point of relevance (eg giving the answer of an initial question in response to subsequent unrelated questions). Pathognomonic of organic brain disease. Pressure of speech Rapid or hurried sp eech, often occurs with \202 ight of ideas. Psychosis Extreme disorders of thinking and p erception, often involving delusions and hallucinations, with loss of insight. Thought bloc king A feature of schizophrenia in which a train of thought stops abruptly and, following a pause, a new line of conversation begins. Thought broadcasting More than simply feeling ot hers can read personal thoughts. An experience of thoughts spilling out beyond personal con trol or that, thoughts are being relayed from external sources. Thought insertion Thoughts that are not the patient \200\231s own are put in his mind from outside. Thought withdrawal The feeling that thoughts have been removed or stolen by an external in \202 uence. 604 CHAPTER 14 Psychiatry The psychiatric interview Setting and safety Conduct the interview in a quiet, relatively p rivate and preferably less clinical setting. Many EDs have speci \201 c facilities designe d for this purpose (following speci \201 c joint guidance from the Royal College of Psychi atrists and British Association for Emergency Medicine \200\223 Council Report CR118, 2004 ). Irrespective of this, do not under any circumstances allow the need for privacy to compr omise your safety! Ensure that other staff are easily available and can be summoned immedia tely if necessary. If this is not possible, either conduct the interview within the main ED (in a cubicle or side-room) and/or ensure that other staff are present during the intervie w. Position yourself between the patient and the exit. Approach In the initial interview, focus upon the following: \200 Listen in supportive fa shion and obtain an accurate history of the presenting problem. Assess the mental state, emotions, and attitudes of the patient. \200 Make a formulation (identify the key factors of the present illness, list probable causes, explain why the pat ient became ill, and plan treat- ment). Initial history Take a rapid, thorough history, concentrating upon the following questions: \200 What is the presenting complaint? \200 What factors have caused the patient to pr esent here and now? \200 Is there a past history of psychiatric illness or medication? \200 What does the patient want (advice, treatment or admission)? \200 Are the patient \200\231s wishes appropriate? Ethnic minorities Be aware of the different communities living within the vicinity and take special care to remain sensitive to their needs. Assessment of mental health problems need s to take into account the relevant cultural and religious issues. Language It can be particularly challenging to assess the mental health of patients who do not speak English. The following solutions may be explored: \200 Assessment may be perfor med by an ED or mental health professional who speaks the patient \200\231s language (the ideal result). A health professional from another discipline acts as an interpreter. \200 An interpreter who is not a health professional, but who is trained in mental health issues may be used. Note that children should not be used as interpreters. Similarly, it is not good practice t o rely upon family members to interpret. 605 THE PSYCHIATRIC INTERVIEW Taking a full psychiatric history The extent to which a detailed psychiatric history is req uired in the ED varies according to the circumstances. The key features of a psychiatric hi story are: Presenting complaint List the principal complaints and try to detail the course and severity of each. Ask about the effect of each problem on the person \200\231s life and work. Carefully determine how he came to be referred or why he presented here and now. Whe n was he last well? Past psychiatric history Ask about previous psychiatric or physical ill ness, hospital admissions (particularly if compulsory) and any outpatient contact (eg commu nity psychiatric nurse), day hospital, day centers, or crisis intervention groups. Record p sychiatric or other medications as accurately as possible. Personal and family history Obta in an outline of the patient \200\231s life history: birth, childhood, circumstances of upb ringing (including parental relationships \200\224 marital disharmony, separation, violenc e, adoption, single parent, brought up by a grandparent, etc.). Ask about education, academ ic achievements, and relationships with family or friends. Ask if there has been any recent bereavement and what effect this has had. Work history Is the patient employed? If not, as k about any previous jobs. Ask about the impact of any loss, change, or failure in work on the patient \200\231s life or mental status, and conversely determine if psychiatric or oth er illness has had any effect on employment. Sexual/marital history Gently enquire about re lationships and sexual experiences only where relevant. This may reveal important informati on about the patient \200\231s personality and relationships to others. It may form a major part of the presenting complaint (eg recent ending or change in a relationship or a histor y of sexual abuse). A more detailed account of sexual aberration or fantasy may be required in a forensic examination. Substance misuse Try to estimate alcohol, tobacco, drug, or oth er substance misuse by the patient. Although it may be dif \201 cult to obtain accurate in formation, do not assume that patients always underestimate their consumption of such subst ances. Forensic history Record any previous criminal charges, convictions or contact with t he police, including the dates on which they occurred. Ask if the patient has any present c harges or court actions pending against him. Social circumstances Determine where the patie nt lives and if he shares accommodation with others. Enquire about income and how he is cop ing \201 nancially. Ask if there are any dependents, any outstanding debts, and if he is receiving any form of social support or monetary assistance. Personality Try to describe th e patient \200\231s usual and present mood. How does he feel about himself and about other people? How does he enjoy himself and how does he react to good, bad or stressful events? C orroboration Extremely important information can be gathered from close relatives, GPs, com munity, or social services, and should be sought to verify or enhance information obtained directly from the patient. 606 CHAPTER 14 Psychiatry Mental state examination Having taken an appropriately thorough history, make an assessment of the patient \200\231s mental state. If the patient is violent, disturbed, or for some o ther reason unable to provide background history, the information or observations gathered, whilst assessing mental state become even more crucial to diagnosis. Appearance and behavior Gather information from the moment the interview begins. Is the pat ient appropriately dressed; is he clean and tidy, or neglected? Does his general posture, b ody movement, and facial expression suggest fear, anxiety, aggression, withdrawal, detachme nt, or low mood? Does he maintain eye contact? Does he respond appropriately to external st imuli or is he easily distracted? Does he appear to be hallucinating or responding to no ob vious stimuli? Are there any abnormal movements, tics, grimaces, or dystonic movements? Not e whether behavior is steady and consistent, or labile and unpredictable. Speech Describe the rate, volume, intonation, and spontaneity of speech. Note the presence of dysarthria or dysphasia. Record any examples of invented new words (neologisms), unusual phrases, perseveration, or garbled speech verbatim. Note vagueness, over-preciseness, or s udden switching to new themes or subjects ( \202 ight of ideas). Mood Taking cues from appearance and behavior, enquire about the patient \200\231s prevaili ng mood, opinion of himself, and view of the future. Enquire about suicidal thoughts and th oughts of harm to others. Ask about disturbances in sleep, appetite, libido, concentration, and mood variations during a typical day. Ask about irritability or memory disturbance (pa rticularly of short-term memory).