Lecture - PICU Flashcards
What is the aim for PICU?
Secure environment for those who cannot be safely managed in an open psychiatric ward
What are the differences between open psychiatric wards and PICU?
PICU has…
- Most disturbed patients who are difficult to manage
- All patients need to be detained under the mental health act (MHA)
- Physical aggression is the most common reason for aggression
- Higher levels of nursing staff and HCAs
- Open plan design to enhance observation, usually locked - 360 view of patients’ bedrooms
- Training of staff in de-escalation, rapid tranquilisation and physical restraint
- Average length of stay is usually 6-8 weeks
- Usually own Seclusion rooms
- Additional resources like gym and garden are available
What is the PICU admission criteria?
Patient is at risk to themselves or others in the context of a mental disorder
Behaviour seriously compromises the physical/psychological wellbeing of self or other
All patients must be over 18
Detained under MHA
Risks include:
- abuse (verbal/sexual/physical)
- property damage
- vulnerability (e.g. due to sexual disinhibition or elation)
- absconscion risk
What are 2 differences between section 2 and 3?
Length S2: 28 days, S3: 6 months
Aim: S2: admission for assessment of mental disorder, S3: admission for treatment of mental disorder
What is section 37?
Hospital order by court
Judge puts an order that the patient should not go to prison but to a hospital
Lasts 6 months but can be extended
What is a section 41?
Hospital order + restriction order by court
Judge order to take patient to hospital
Usually for risky forensic patients
Lasts 6 months but can be extended
What kind of medications are used in PICU?
- Antipsychotics
- Mood stabilisers
- Antidepressants
- Benzodiazpines
- Z drugs - used for insomnia
- Antihistamines
- HDAT - high dose antipsychotic therapy - PICU often uses higher doses than are used on other wards
These are used to reduce risk and not to make the patients like ‘zombies’.
What therapies are used in PICU?
- Brief psychology
- Art therapy
- Music therapy
- Gardening/reading
What behavioural therapies are used in PICU?
- 1:1 nursing sessions
- Verbal de-escalation
- Care planning
What emergency management is used in PICU?
- Rapid tranquilisation
- Acuphase - if rapid tranqilisation doesn’t work
- Physical restraint
- Seclusion
What is the aim or rapid tranquilisation?
Used to reduce imminent risk and avoid prolonged intervention
- Reduces psychological or physical suffering
- Reduces risk of harm to others
What form is rapid tranquilisation given?
- Always consider ORAL medication first
- Check medical history, allergies, ECG before administering - some of the medications used e.g. haloperidol, can cause arrhythmias.
- Requires close physical health monitoring after RT - nurses observe vitals once every 15 mins
What is the first question to ask if considering administering rapid tranquilisation? What is 1st and 2nd line?
Has the patient got a history of antipsychotic use?
1st line is always oral benzodiazepine i.e. 2mg lorazepam because this is short lasting (2-4 hours) and quick acting (within 15mins-1hr).
2nd line (if still aggressive) - haloperidol (up to 5mg) NB: arrhythmias or prolonged QTc then do not give haloperidol as this can cause prolonged QTc and lead to fatal arrhythmia.
This is the 5+2 rule.
If the patient has used antipsychotics in the past, what can you give in rapid tranquilisation?
1st line - 2mg lorazepam (wait 15 mins to 1hr)
2nd line - 5mh haloperidol or 25-50mg promethazine (ECG must be normal and no cardiac illness)
If the patient has an abnormal ECG/cardiac disease and you have already given them lorazepam, what is the next step? What caution must be taken with this drug?
Olanzapine 10mg IM
DO NOT give within 60mins of lorazepam as this puts patient at risk of respiratory depression
Summary
