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)
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
(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
- Form
- Perception
- hallucination
- Cognition
- orientation etc…
- Insight, judgement and capacity
- do they think their thoughts are normal
- do they make rational decisions for simple problems
- 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.
- violent, has a weapon
- extremely agitated, requiring restraint
- agitated, bizarre, psychotic or suicidal ideation
- symptoms of anxiety depression without suicidal ideation
- compliant, cooperative communicative
- 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
- 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