Management of Eating Disorders in the Emergency Department


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also:

    Engaging with and assessing the adolescent patient
    Mental state examination

    Key Points:  

    1. Children and young people (CAYP) with eating disorders (EDs) can present medically unstable with cardiovascular complications, electrolyte imbalances and dehydration requiring medical admission.
    2. CAYP with EDs can present mentally unstable with suicidal ideation, escalating ED compensatory behaviours or comorbid psychiatric disorders requiring urgent mental health assessment.
    3. CAYP with EDs should have measurements of weight, BMI, postural HR and BP, an ECG and initial blood testing.
    4. CAYP with EDs are at risk of refeeding syndrome; medically unstable patients should not commence feeding until blood results have been reviewed and a meal plan decided with the inpatient team.

    Background

    EDs are potentially life-threatening conditions - Anorexia Nervosa has the highest mortality of any psychiatric disorder.

    Early intervention is the best way to assist with successful recovery. It is important to recognise warning signs and refer to the appropriate service.

    How to assess:

    Red flag features in Red

    History: 

    • Is this a new diagnosis or a CAYP presenting with established ED?
    • Weight profile
          • Current weight, pre-morbid weight, percentage weight loss, timing of weight loss (weight loss 10-15%+ in 3-6 months is significant)
          • Onset of menarche and recent menstrual history
        • Risk of suicide and self harm
        • A broader psychosocial assessment may include a HEADSSS screen (See Engaging with and assessing the adolescent patient)
        • If first presentation and diagnosis is in doubt, helpful questions include:
            • Concern over weight
            • Body image concerns and fear of weight gain
            • Dietary habits
            • Associated behaviours with eating eg. Eating slowly, eating in isolation, particular rituals around mealtimes
            • Weight control measures (e.g. exercise, laxatives, purging)
            • Binge eating
          • If < 12 years old please discuss with senior doctor  

          Examination: 

          • Postural heart rate and postural blood pressure
          • Temperature
          • Weight, height and BMI  

          Management

          Investigations: 

          • 12-lead ECG
          • Blood tests (all patients) - FBE, U&E, Ca, Mg, PO4, LFTs, venous blood gas, glucose
          • Blood tests (new diagnosis) - ESR, thyroid function, coeliac screen
          • Consider nutritional testing (if not done in the last 3 months) including iron studies, B12, red cell folate, vit D and zinc.    

          Consider medical admission for those with:

          • Significant electrolyte disturbance (K < 3.0)
          • HR ≤ 50bpm
          • Postural HR increase ≥ 30bpm
          • Resting systolic BP ≤ 80mmHg
          • Postural systolic drop ≥ 20mmHg
          • Hypothermia < 35.5C
          • Dehydration
          • Arrhythmia or prolonged QTc > 0.45s
          • Weight <75% of their expected body weight or rapid weight loss (>10-15% in 3-6 months is significant)
          • Out of control ED compensatory behaviours e.g. prolonged fasting/ inability to eat at home/ uncontrolled purging and exercising
          • Admission may be appropriate in rare circumstances where community management is not effective

          Feeding:

          Feeding should only commence after blood results have been reviewed and the patient has been discussed with admitting team.

          The agreed feeding plan should be commenced as soon as possible and ideally in the emergency department.

          There is a risk of refeeding syndrome, potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients being refed. The hallmark biochemical feature of refeeding syndrome is hypophosphataemia.    

          Cardiac monitoring:

          Consider cardiac monitoring after discussion with the admitting consultant for:

          • severe electrolyte disturbance (e.g. K <2.5)
          • HR <45 bpm
          • HR <40 bpm asleep  

          Psychiatric Assessment:

          If medically stable but concerns about mental health (e.g. suicidal, comorbid psychiatric disorder or out of control ED compensatory behaviours), discuss with local mental health team.  

          Consider consultation with local paediatric or adolescent team when:

          CAYP are medically unstable (as above) or requiring admission.

          To discuss appropriate follow up of CAYP being discharged from emergency. 

          Consider secondary consultation with RCH or MMC when:

          Managing CAYP with EDs, especially those requiring refeeding or those who are medically or mentally unstable (as above).

          RCH Contact:

          Eating Disorders Clinical Nurse consultants 9345 6533

          Adolescent Medicine Consultant on call 9345 5522 page via switchboard

          MCH Contact:

          Eating Disorder Clinical Nurse Consultant in business hours 9594 4642

          Adolescent Med Consultant on call 9594 6666 via switchboard

          Consider transfer when:

          For medically unstable patients who require escalation of care beyond capacity/comfort of the local team/facility

          For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

          Consider Discharge when:

          • Medically stable
          • Mental health assessment completed
          • Appropriate medical and/or mental health follow up arranged.

          Last updated August, 2017