Clinical Points

Question 1

Summary charts - review the flow charts tony has in the first note of this section

Answer 1

They’re pretty awesome!

Question 2

Reasons for confidentiality breach

Answer 2

driving safety concerns

suicidal ideation / plan

homicidal ideation / plan

issues involving Children’s Aid Society

Question 3

What is the #1 risk factor for aggression

Answer 3

Past history of violence including legal problems

Question 4

What are standard PRN medications and their doses used for sedation for an aggressive patient?

Answer 4

Olanzapine (Zydis) 5-10mg PO Q6H PRN with maximum of 20mg over 24 hours

Lorazepam (Ativan) 1-2mg PO/IM Q4H PRN with maximum of 8mg over 24 hours

Haloperidol 5-10mg PO/IM Q6H PRN with maximum of 20mg over 24 hours

Question 5

What are standard PRN medications and their doses used for sedation for an aggressive elderly patient?

Answer 5

Loxapine 5-10mg PO/IM Q4H PRN

Trazodone 25mg PO Q4H PRN

Question 6

PRN to use in an aggressive patient allergic (dystonia) to haloperidol

Answer 6

Loxapine 25-50mg PO/IM PRN

Methotrimeprazine 50-100mg PO/IM

Question 7

PRN for severe aggression

Answer 7

Haloperidol 5-10mg PO/IM PRN

Lorazepam 2mg PO/IM PRN

Zuclopenthixol acetate (Clopixol accuphase) 50-150mg IM Q72H PRN, which is long lasting and last line treatment for severe aggression

also consider physical restraints for 24 hours PRN

Question 8

What is dystonia

Answer 8

sustained muscle contraction, usually an acute reaction to antipsychotics

Question 9

Potential severe complications of dystonia

Answer 9

oculogyric crisis (eyes rolling to back of head) and laryngospasm (can close airway causing death)

Question 10

Dystonia management

Answer 10

1st line: Benztropine 1-2mg PO/IM BID PRN for dystonia

2nd line: Lorazepam (Ativan) 2mg IM or Diphenhydramine (Benadryl) 50mg IM

Question 11

CIWA medication protocol

Answer 11

standard protocol:

Lorazepam 2mg TID straight PLUS
Lorazepam 2mg Q1H PRN for signs of withdrawal (heart rate >100, systolic blood pressure >140, tremor)

Diazepam (Valium) can be used, which has long half life and self-tapering, but should be avoided in liver cirrhosis

note 10mg Diazepam = 2mg Lorazepam only LOT (Lorazepam, Oxezapam, Temazepam) benzodiazepines are used for patents with liver cirrhosis

self tapering protocol using Diazepam: 10mg TID on day 1; 10mg BID on day 2; 10mg daily on day 3; then stop

Question 12

What is the modified sadpersons scale

Answer 12

Calculates the risk of suicide

S: Male sex (1 point)
A: age 15-25 or >59 (1 point)
D: Depression or hopelessness (2 points)
P: Previous suicidal attempts or psychiatric care (1 point)
E: Excessive ethanol or drug use (1 point)
R: Rational thinking loss (psychotic or organic illness) (2 points)
S: Single, widowed or divorced (1 point)
O: Organized or serious attempt (2 points)
N: No social support (1 point)
S: Stated future intent (determined to repeat or ambivalent) (2 points)

score 0-5 = low risk of suicide, so may be safe to discharge depending on circumstances

score 6-8 = requires psychiatric consultation

score >8 = requires hospital admission

Question 13

What is the strongest predictor of future successful suicide

Answer 13

previous suicide attempts

Question 14

What are 5 areas that need to be asked and documented about when exploring suicidality

Answer 14

1) Plan
2) Previous attempts
3) Rapport and engagement
4) Risk factors
5) Protective factors

Question 15

Mental health act forms and their meaning

Answer 15

form 1 = application by physician for psychiatric assessment

form 2 = order for examination under section 16

form 3 = certificate of involuntary admission

Question 16

Form 1 requirements

Answer 16

physician must have personally examined patient in a formal clinical assessment within the last 7 days

person must have mental disorder
specific diagnosis is not mandatory, but need finding of some sort of mental disorder

patient must satisfy either box A or box B criteria

clinically, form 1 completed for patients with any of the following: acute safety risk (suicide, aggression), impulsivity (e.g. bipolar mania), ambivalence, psychosis, impaired insight or judgment (e.g. bipolar mania, schizophrenia psychosis)

Question 17

Box A criteria

Answer 17

Box A criteria usually filled out by any physician

patients must satisfy past / present test and future test

past / present test = reasonable cause to believe that patient will fulfill 1+ of the following:
threatened / is threatening to cause bodily harm to self
attempted / is attempting to cause bodily harm to self
behaved / is behaving violently towards another person
caused / is causing another person to fear bodily harm from patient
showed / is showing lack of competence to care for self

future test = patient is suffering from mental disorder that will likely result in 1+ of the following:
serious bodily harm to self
serious bodily harm to another person
serious physical impairment of self

Question 18

Box B criteria

Answer 18

box B requirements usually filled out by psychiatrist patient must satisfy all 5 criteria

1) past test: patient received treatment for mental disorder that would have resulted in 1+ of following if left untreated:
serious bodily harm to self
serious bodily harm to another person
substantial mental or physical deterioration of self
serious physical impairment of self

2) patient clinically improved on treatment
3) patient is incapable to consenting to treatment for mental disorder and consent from substitute decision maker was obtained
4) patient is suffering from same disorder as outlined in 1-3

5) future test: given patient’s mental disorder, patient is likely to do 1+ of the following:
cause serious bodily harm to self
cause serious bodily harm to another person
suffer substantial mental or physical deterioration
suffer serious physical impairment

Question 19

How long is a form 1 valid for

Answer 19

7 days to bring the patient to a facility

72 hours once patient brought to a facility

Question 20

What form needs to be provided to patient with completion of a form 1

Answer 20

Form 42

Question 21

What is a form 2

Answer 21

form 2 can be obtained by any person, which is completed by Justice of Peace

patient must meet same criteria as form 1 (Box A requirement)

form 2 allows police to bring the person to a health care facility for psychiatric assessment

Question 22

What does Section 17 read

Answer 22

police officer can bring person to a health care facility for psychiatric assessment for reasons listed on form 1

Question 23

What is a voluntary patient

Answer 23

gave informed consent for admission, capable of consenting, not at risk of escaping, voluntarily admitted into facility

Question 24

What is an informal patient

Answer 24

patient is not capable of consenting to staying in hospital and substitute decision maker gives consent to hospitalization for patient

Question 25

How long does form 3 last

Answer 25

Allows detainment and admission for 2 weeks

Question 26

Requirements for form 3

Answer 26

patient must be either from form 1 or already admitted as an inpatient into the hospital

patient cannot be from form 2, so patients from form 2 must then undergo form 1 then form 3 form

must be completed by a physician different than the physician who filled out form 1

patient must satisfy criteria, which is the same as form 1

Question 27

Types of patients on a form 3

Answer 27

Voluntary, involuntary and informal

Question 28

Form 4 requirements

Answer 28

Meet criteria (same as form 1)

Patient notified with form 30 each time a form 4 is filled

Question 29

Form that needs to be provided to patient with form 3

Answer 29

Form 30

Question 30

Duration of form 4s

Answer 30

if filled for the 1st time, form 4 is valid for 1 month

if filled for the 2nd time, form 4 is valid for 2 months

if filled for the 3rd time, form 4 is valid for 3 months

Question 31

What is a community treatment order

Answer 31

community treatment order requires patient by law to comply with outpatient treatment plan

Question 32

Requisites for community treatment order

Answer 32

consent must be given by patient or substitute decision maker

patient must have history of admission and meet form 1 criteria

failure to comply with treatment will result in person being readmitted to hospital

Question 33

What does informed consent involve

Answer 33

nature of treatment

expected benefits

risk and side effect of treatment

alternative treatment or course of action

likely consequence of not having the treatment

Question 34

How to declare patient incapable

Answer 34

1. Give them form 33
   Rights advisor will advise them of their rights
2. Document in the chart