For January we’ll look at patients with mental health or substance-related presentations. This was a patient presenting with overdose, being cared for in the ambulatory area of the department.
This was the first live-streamed session. I hope shortly we will be able to do this with the majority of simulations so that the wider team can benefit.
The simulated case:
A man in his 20s presenting after an overdose of mirtazapine and propranolol, tachycardic with some muscle ache but with normal blood pressure.
The healthcare assistant recorded observations and recorded the patient’s history. The importance of safeguarding children was explained and the details of the patient’s children were recorded.
TOXBASE was consulted for management guidelines. It was decided to move the patient to majors due to the tachycardia, with a view to move to CDU once medically fit for liaison psychiatry consultation.
What did we think?
In debrief we discussed:
We talked about how we explain to patients the need for information about children in their care. This can clearly be an emotive topic and one in which intentions can be misunderstood. The group consensus was for a focus on the identification and provision of support as an outcome.
Remember that adults who present who do not have children may still care for parents or other vulnerable adults - ask about this.
Ask about vulnerability factors: do they feel safe at home? Do they have a support network? Have a look at the SCARF acronym in the “to-do” section below.
The specifics of these medications:
We talked about some of the specific risks with propranolol (e.g. hypotension - potential to be prolonged especially if sustained release) and mirtazapine (serotonin syndrome) and importance of ECG (QTc), bloods (e.g. CK) and a good examination.
We sometimes see people repeatedly attend with overdose. So it’s really important that we do maintain empathy and don’t burn out. Men with EUPD may be more likely to experience aggression and attend via police custody so it’s important to maintain the same appreciation that they need our help and support.
Referring to PLNs:
Have a look at the recent referral guidance sent out by email 14/01/21: “In brief the main message is refer early - from START or immediately behind START. Referrals can be made by medical or nursing staff after initial assessment… Mental health assessment can be made in parallel with medical treatment and referral for such assessment should not be delayed”.
Consider the likelihood of the cannula being used before putting one in “just in case”. One review has suggested a median of 32.4% cannulas inserted in ED are not subsequently used, and clearly there are well documented risks of them.
Have a read of the email on referrals from 14-01-21. It also contains links to the RCEM mental health toolkit [ ]
Think about using “SCARF” to cover vulnerability factors with the patient, and ask about them directly: feeling Safe at home? Are there others with Control? Abuse? Relationships? Family/friends? [ ]
If you took part in the sim or watched on the livestream, you can use this blog as a starter to reflect on your own experience of it [ ]
Blog by: James Keitley ED sim fellow
For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author.
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