Acute mental health problems
Some mental health problems confer a greater risk of suffering from major
trauma. Obvious examples are drug or alcohol dependency, but illnesses which
have increased degrees of impulsiveness, risk taking and suicidal behaviour are
over-represented in major trauma cohorts. Therefore, all services dealing with major
trauma patients should be sensitive to the psychological needs of their patients.
In the acute medical setting the prime additional problems encountered tend to be:
- safety of acutely suicidal patients
- drug/alcohol dependency and withdrawal
- the behavioural sequelae of traumatic brain injuries (see sections 8.? – 8.?).
1. Post suicide attempt
Any trauma patient who has recently committed a suicide attempt should be reviewed by a psychiatric team as soon as they are able to give an accurate history. If there is a delay before psychiatric assessment (which will provide an accurate risk assessment and management plan), keeping the patient safe whilst continuing to treat the traumatic injuries is important, including 1:1 care when required.
2. Alcohol withdrawal
Alcohol misuse is common amongst major trauma patients but only a minority of
this group will enter into frank alcohol withdrawal, although this is often a difficult
problem to detect when a patient has had a significant head injury and little collateral
history is available.
Symptoms of alcohol withdrawal (peak at days two to five)
- tachycardia
- sweating
- tremor
Mental state changes include:
- insomnia
- anxiety
which can develop into delirium tremens
- persecutory delusions
- visual hallucinations
- agitation
- seizures
Untreated delirium tremens has a mortality as high as 10%.
See local hospital protocol for treatment.
Wernicke’s encephalopathy
- easily missed post trauma
- result of chronic thiamine (vitamin B1) deficiency secondary to malabsorption (usually alcohol induced)
Triad of
- confusion
- ataxia
- ophthalmoplegia
although often only confusion is present. It can be hard to distinguish from the numerous other causes of confusion immediately post trauma, especially where a head injury and no collateral history is present. Where alcohol dependency is suspected it should be treated pro-actively as it can progress to Korsakoff’s syndrome, an irreversible inability to lay down new memories. Treatment and prophylaxis is via parenteral vitamin B complex.
Summary of managing acute mental health problems following trauma:
- Involve local psychiatric teams early in the assessment of suicide attempts.
- Have a low index of suspicion for alcohol withdrawal and Wernicke’s.
- Treat suspected alcohol withdrawal and Wernicke’s pro-actively
- Obtain a good collateral history regarding suspected suicide attempts and pre-existing drug/alcohol use
Do not:
- be afraid to ask about mental health symptoms, including suicidal thoughts and plans
- consider alcohol withdrawal and Wernicke’s as diagnoses of exclusion.