Tasty Morsels of EM 120 – #FRCEM Psych and eating disorders

7 Aug

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

RCPsych have the wonderfully entitled MARSIPAN guidelines for sick anorexic patients and a lot of it is right in our wheelhouse. RCEM has a useful toolkit on mental health in the ED. NICE 2004 has one on self harm (p17 most relevant to us)

Describe some risk factors for assessing suicide risk

These form the SADPERSONS scale

  • Sex male
  • Age <19>45
  • Depression/Hopelessness +2
  • Previous suicide or psych care
  • Excess alcohol/drug
  • Rational thinking Loss +2
  • Separated (include widowed)
  • Organise, serious attempt +2
  • No social support
  • Stated future intent +2

OHEM quotes <6 as possibly safe for discharge

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Describe the mental state examination?

(Geeky Medics has a nice summary because med students are all better at this than us)

  • Appearance
    • clothing
    • grooming
  • Behaviour
    • eye contact
    • facial expression
    • arousal (agitated or calm)
    • cooperation
  • Speech
    • rate
    • quantity
    • tone
    • volume
    • fluency
  • Mood and affect
    • mood – sustained emotion that can alter someone’s perception of the world – you ask questions about this
    • affect – immediately expressed and observed emotion – you observe this
  • Thought
    • Form
      • Speed
      • Coherence
    • Content
      • delusions
      • suicidality
    • Possession
      • insertion
      • withdrawal
      • broadcasting
  • Perception
    • hallucination
  • Cognition
    • orientation etc…
  • Insight, judgement and capacity
    • do they think their thoughts are normal
    • do they make rational decisions for simple problems

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What are RCEM standards for mental health in the ED?

  • patients who have self-harmed should have a risk assessment
  • document
    • prior mental health issues
    • a mental state examination
    • provisional diagnosis
    • referral and follow up
  • mental health team should review within 1 hr of referral
  • an appropriate facility should be available
    • 2 doors, both opening both ways
    • no potential missiles of ligature points

While not in the RCEM standards NICE 2004 does recommend the Australian Mental Health triage tool. You’ll find it in the OHEM too.

  1. violent, has a weapon
  2. extremely agitated, requiring restraint
  3. agitated, bizarre, psychotic or suicidal ideation
  4. symptoms of anxiety depression without suicidal ideation
  5. compliant, cooperative communicative

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What should worry us in eating disorders?

  • severe anorexia BMI<15
  • low pulse (<40)
  • low BP especially if postural
  • SUSS Test (Sit Up Squat Stand)
    • 1) sit up from supine without using hands
    • 2) form standing squat and stand again without using hands
    • Score for 1) and 2) separately
      • 0
      • 1 with hands only
      • 2  with difficulty
      • 3 with no difficulty
  • Bloods
    • Sodium <130 (note can be from water loading to hide weight loss or from SIADH from a pneumonia
    • low potassium, sometimes from purging or laxatives
    • raised transaminases
    • Gluc <3
    • raised urea and creatinine  – hugely increases risk for refeeding issues
    • ECG changes are brady or potassium related

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How is the mental health act relevant?

  • Section 3 of the mental health act may be used for compulsory treatment
  • this must be applied by a mental health professional and not by us so always get expert advice here
  • several criteria must be applied
    • presence of mental disorder (eg anorexia nervosa)
    • in patient treatment needed (eg NG or IV feeding…)
    • this treatment must be necessary for their safety

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