Psychiatric Emergencies
Paul Scavella
University of the West Indies
Psychiatry Clerkship
18/03/2016
Definitions
Emergency
unforeseen combination of
circumstances which calls for immediate
action
Medical emergency defined as a
medical condition which endangers life
and/or causes great suffering to individual
Psychiatric disturbances of thought,
affect and psycho motor activity threat
to his/her person or people in the
environment
Adjunct side effects from medication
Definition contd
Psychiatric
Emergencies require
immediate evaluation by a
Psychiatrist to determine the
nature and severity of the
condition.
Note: Psychiatric Emergencies
may affect both adults and
children.
Characteristics
Any
condition/situation making
the patient and relatives seek
immediate treatment
Disharmony between the patient
and environment
Sudden disorganisation in
personality
Affecting socio-occupational
functioning
Objectives for emergency
intervention
Safeguard
the life of the patient
Reduce anxiety of family
Enhance emotional security of
others in the environment
Types of Psychiatric
Emergencies
Suicide
or deliberate self harm
Violence/Excitement
Stupor
Panic
Withdrawal Sx of drug dependence
Delerium Tremens
Alcohol
or drug overdose
Epilepsy or Status Epilepticus
Severe Depression
Iatrogenic emergencies
Side effects of psychotropic drugs
Psychiatric complications of drugs used in medicine
Abnormal
response to a stressful situation
General guidelines of management
for Psychiatric Emergencies
Handle with utmost tact and
speech so that well being of
other patients is not affected
2. Act in a calm manner to prevent
other clients from getting
anxious
3. Shift the client as early as
possible to a room where they
can be safe guarded against
injury
1.
General guidelines of management
for Psychiatric Emergencies
Ensure that all other clients are
reassured and that routine
activities proceed normally
5. Psychiatric emergency overlap
medical emergencies and staff
should be familiar with both
4.
Epidemiology
In the USA, Psychiatric Emergency Rooms are used equally
by men and by women and are used by more single than
married individuals
About 20 % of the patients are suicidal and 10% are
violent.
The
more common diagnoses are mood disorders,
schizophrenia and Alcohol Dependence.
40%
of persons need hospitalization.
Most
visits occur during the nights.
Psychiatric
Emergencies are NOT increased during full
moon or Christmas season.
Prevalence
Rate
of psychiatric emergencies
in non-psychiatric institutions
estimated at anywhere from 10%
- 60%
All physicians need basic
knowledge of the diagnostic and
therapeutic steps to be taken in
psychiatric emergencies
Treatment settings
Most
emergency psychiatric evaluations are
done by non-psychiatrists in a general medical
emergency room setting (like in the Bahamas),
but specialized psychiatric services are
increasingly favored.
Regardless
of the type of setting, an
atmosphere of safety and security must prevail.
An
adequate number of staff members,
including psychiatrists, nurses, aides and social
workers must be present at all times.
Treatment settings
Immediate
access to the medical emergency room
and to appropriate diagnostic services is necessary
because one third of medical conditions present with
psychiatric manifestations.
Ideally,
the full spectrum of psychopharmacological
options should be available to the psychiatrist.
Whenever
possible, agitated and threatening patients
should be sequestered from the nonagitated.
Seclusion
and restraint rooms should be located close
to the nursing station for observation.
Evaluation
Primary
goal is timely
assessment of the patient in
crisis
Physician must
Make an initial diagnosis
Identify precipitating factors and
immediate needs
Begin treatment or refer to the most
appropriate treatment setting
Evaluation
Evaluation
The
standard psychiatric
interview consisting of a history,
mental status exam, when
appropriate and depending on
the emergency room, a full
physical and ancillary tests
For Psychiatric emergencies, the
physician must be able to
introduce modifications as
needed.
Evaluation
The
emergency evaluation should
address the following:
Is it safe for the patient to be in the
Emergency room?
Is the problem organic, functional or
a combination?
Is the patient psychotic?
Is the patient suicidal or homicidal?
To what degree is the patient capable
of self-care?
Medical or Psychiatric
Conditions
such as DM, Thyroid
disease, acute intoxications, withdrawal
states, AIDS and head traumas can
present with prominent mental status
changes that mimic common
psychiatric illnesses
Such conditions may be life-threatening
if not treated promptly
Sometimes once labeled psychiatric
patients with mental illnesses may be
overlooked and deteriorate clinically
Features that point to medical
cause of a mental disorder
Acute
onset (within hours or minutes,
with prevailing)
First episode
Geriatric age
Current medical illness or injury
Significant substance abuse
Non-auditory disturbances of perception
Neurological symptoms LOC, seizures,
head injury, change in headache
pattern, change in vision
Specific Interview
Situations
Psychosis
physicians must be prepared to
structure or terminate an interview to limit
the potential of agitation or regression
Depression and potentially suicidal
should always ask about suicidal ideas as
part of every MSE, especially if the patient
is depressed
Violent patients may be violent for many
reasons; must attempt to ascertain the
underlying cause of the violent behaviour
as cause determines intervention
History signs and symptoms of
suicidal risk
Previous
attempt or fantasized suicide
Anxiety, depression, exhaustion
Availability of means of suicide
Concern for effect of suicide on family
members
Verbalised suicidal ideation
Preparation of will, resignation after agitated
depression
Proximal life crisis, such as mourning or
impending surgery
Family History of suicide
Pervasive pessimism or hopelessness
Treatment goals
Treatment of Emergencies
Psychotherapy
In an emergency psychiatric
intervention, all attempts are made
to help patients self-esteem
Empathy is always important
No single approach is appropriate for
all persons in similar situations
When clinician does not know what
to say listening is best
Treatment of Emergencies
Pharmacotherapy
Major indications for the use of
psychotropic medication in
emergency room include:
Violent or assaultive behaviour
Massive anxiety or panic
Extrapyramidal reactions such as
dystonia and akathisia
Note laryngospasm is a rare form of dystonia
and psychiatrists should be prepared to
maintain on open airway wit intubation
Treatment of Emergencies
Restraints
Used when patients are so
dangerous to themselves or others
that they pose a severe threat that
cannot be controlled in any other
way
Patients may be restrained
temporarily to receive medication or
if medication cannot be given
Tips when using restraints
Preferrably
5 or a minimum of 4 persons should be used
to restrain the patient (leather are safest type)
Explain to the patient why he or she is going into
restraints
A staff member should always be visible and reassuring
the patient
Reassurance helps alleviate the patients fear of
helplessness, impotence and loss of control
Patients should be restrained with legs spread-eagled
and one arm to one side and the other over the patients
head. IVs should be placed in the event they need Fluids
or medication
Should be checked periodically for safety and comfort
Document reason for the restraints, course of treatment
and response to treatment with restraints
Treatment for
Emergencies
Disposition
In some cases admitting or
discharging the patient is not
optimal
Some conditions have to be
managed in an extendedobservation setting, e.g., adjustment
reaction to a traumatic event
Best to admit patient voluntarily,
however very difficult to
Suicide
One
of the commonest
psychiatric emergencies
Commonest cause of death
among psychiatric patients
Defined as the intentional taking
of ones life in a culturally nonendorsed manner
Suicide
Aetiology
Psychotic Disorder
1.
2.
3.
Major Depression
Schizophrenia
Substance abuse
Dementia
Delirium
Personality disorder
Physical Disorder
Chronic or incurable physical disorders like Cancer, AIDS
Psychosocial Factors
Failure in exams
Marital problems
Loss of loved one or object
Isolation and alienation from social groups
Financial & Occupational difficulties
Suicide
Risk
Factors
Age > 40
Male gender
Single
Previous attempts
Depression: Higher risk after response to treatment,
Higher risk in week after discharge
Suicidal preoccupation
Alcohol or drug dependence
Chronic illness
Recent serious loss or major stressful life event
Social isolation
Higher degree of impulsivity
Management
Be
aware of the warning signs
Monitor the patients safety
needs
Acute psychiatric interview
Counseling & Guidance
Deal with ongoing life stressors and
teach new coping skills
Treatment
disorders
of psychiatric
Violence/Excitement/Aggressive
Behaviour
Physical
aggression by one
person on another
During this stage patient will be
irrational, uncooperative,
delusional and assaultive
Violence/Excitement/Aggressive
Behaviour: Aetiology
Organic
Psychiatric Disorders
Delirium
Dementia
Wernicke Korsakoff psychosis
Other
pyschiatric disorders
Schizphrenia
Mania
Agitated depression
Substance withdrawal
Epilepsy
Acute stress reaction
Panic disorder
Personality disorder
Violence/Excitement/Aggressive
Behaviour: Management
Reassurane
Sedation
if necessary
Diazepam 5 10 mg slow IV
Haloperidol 2 10 m IM/IV
Chlorpromazine 50 100 mg IM
Collect
detailed history and explore cause
Complete physical exam
Provide care and do due diligence
Physical restraints last resort
Stupor & Catatonic
Syndrome
Clinical
syndrome of akinesis and
mutism often associated with
catatonic signs and symptoms
Catatonic synd. Any disorder
which presents with at least 2
catatonic signs
Negativism, mutism, stupor,
ambitendency, echolalia, echopraxia,
stereotypes, verbigeration,
excitement and impulsiveness
Stupor & Catatonic Syndrome:
Management
Ensure
patient airway
Maintain hydration
History and PE
Ancillary investigations before
starting treatment
Provide care for unconscious
patient
Skin, nutrition, elimination, personal
hygiene
Panic Attacks
Episodes
of acute anxiety and
panic occurs as part of psychotic
or neurotic illness
Manifestations
Palpitations (Anxiety MCC)
Sweating, tremors, feeling of
impending death
Chest pain, nausea, abdominal
distress
Paresthesia, Hot flushes
Panic Attacks:
Management
Give
reassurance
Find cause
Injection of Diazepam 10mg or
lorazepam 2 mg in acute setting
Counsel patient and relatives
Cognitive Behavioural therapy
Victims of Disaster
People
who have survived a
sudden, unexpected,
overwhelming stress
Features
Anger, Frustration, Guilts
Numbness, Confusion
Flashbacks, Depression
Victims of Disaster: Management
Treatment
of the life-threatening
physical problem
Intervention
Listen attentively, dont interrupt
Acknowledge understaning of the pain and
distress
Console if appropriate (pat on the shoulder)
Dont ask them to stop crying
Group
therapy
Benzodiazepines can be given to reduce
anxiety
Hysterical Attacks
A
hysteric may mimic
abnormality of any function which
is under voluntary control
Hysterical fits
Hysterical ataxia
Hysterical paraplegia
Hysterical attacks:
Management
Help
patient realise the meaning
of the symptoms and help them
find alternative ways of coping
with stress
IV pentothal is useful
Relieve anxiety amonth family
members
Delirium Tremens
Life
threatening alcohol
withdrawal syndrome peaks a
days 2 to 5 after last drink
Characterised by delirium,
hyperthermia, tachycardia,
seizures
TIME
6 to
8 hours
to 12 hours
12
to 24 hours
During
72 hours but
can be up to one
week.
SYMPTOMS
TREMULOUSNESS
(shakes or jitters)
Psychotic and
perceptual symptoms
Seizures
Delirium Tremens
(DTs)
ALCOHOL WITHDRAWAL
TIMELINE
Delirium Tremens:
Management
Best
treatment for DTs is prevention.
Once Delirium sets in, IV benzodiazepines is best eg,
Lorazepam IV at 0.1mg/kg or if available
chlordiazepoxide (librium), should be given orally
every 4 hrs
Antipsychotic medications that may reduce the
seizure threshold in patients should be avoided.
High calorie, high-carbohydrate diet supplemented
by Multivitamins is important.
Be careful with physical restraints, and remember
hydration is essential.
Warm, supportive psychotherapy in the treatment of
DTs is essential since patients are often frightened
and anxious.
Epileptic Furor
Following
an epileptic attach
patient may behave strangely
and become excited or violent
Management
Diazepam 10 mg IV
Haloperidol 10 mg IV
Drug Adverse Effects
Neuroleptic
Malignant Syndrome
AE of Antipsychotics
FEVER mnemonic
Fever
Encephalopathy
Elevated Enzyme (CK) and WBCs
Rigidity
Drug Adverse Effects
NMS
Management
Stop the causative drug
Cool the patients body temp
Maintain fluid and electrolyte blance
Dantrolene
Drug Adverse Effects
Serotonin Syndrome
The
diagnosis is usually made by asking questions about your
medical history, including the types of drugs the patient takes.
To
be diagnosed with serotonin syndrome, you must have been
taking a drug that changes the body's serotonin levels
(serotonergic drug) and have at least three of the following
signs or symptoms:
Agitation,
Mental
Muscle
Diarrhea ,Heavy sweating not due to activity Fever
status changes such as confusion or hypomania
spasms (myoclonus), Hyperreflexia ,Shivering, Tremor
AND Uncoordinated movements (ataxia)
Serotonin Syndrome:
Management
Benzodiazepines
such as diazepam (Valium) or
lorazepam (Ativan) to decrease agitation, seizure-like
movements, and muscle stiffness
Cyproheptadine
(Periactin), a drug that blocks
serotonin production
Fluids
by IV
Withdrawal
In
of medicines that caused the syndrome
life-threatening cases, paralytics and intubation may
be necessary to avoid further damage.
Drug Adverse Effects: Lithium
Benzodiazepines
such as diazepam (Valium) or
lorazepam (Ativan) to decrease agitation, seizure-like
movements, and muscle stiffness
Cyproheptadine
(Periactin), a drug that blocks
serotonin production
Fluids
by IV
Withdrawal
In
of medicines that caused the syndrome
life-threatening cases, paralytics and intubation may
be necessary to avoid further damage.
