PSYCHIATRIC EMERGENCIES

INTRODUCTION:
A psychiatric emergency is a clinical application of psychiatry
in emergency settings. Conditions requiring psychiatric
interventions may include attempted suicide, substance abuse,
depression, psychosis, violence or other rapid changes in
behaviour. Psychiatric emergency services are rendered by
professionals in the fields of medicine, nursing, psychology
and social work.

An emergency is a situation that poses an immediate risk to

health, life, property, or environment. Most emergencies
require urgent intervention to prevent a worsening of the
situation
 DEFINITIONS:
 A sudden onset of an unusual, disordered inappropriate
behaviour caused by an emotional and physiological situation.

 A psychiatric emergency is disturbance of thoughts, feelings

or actions that require immediate treatment.

 A psychiatric emergency is an acute disturbance of behaviour,

thought or mood of patient which if untreated may lead to
harm, either to individual or to others in the environment.
OBJECTIVES OF PSYCHIATRIC
EMERGENCIES:
 To safeguard the life of patient.
 To reduce anxiety.
 To promote emotional security of client and family
members.
 To educate client and his family members the ways of
dealing emergency situation by adaptive coping strategies,
problem solving methods.
CHARACTERISTICS OF
PSYCHIATRIC EMERGENCIES:
 Certainconditions or stressor predisposes the client and
family members to seek immediate intervention as they
feel more discomfort.
 Disharmony between client and his environment.
 Sudden unexpected disorganization in person.
 Unable to cope up with stressful situation.
COMMON PSYCHIATRIC
EMERGENCIES:

 Suicide.
 Mania
 Agitated and violent behaviour.
 Panic attack.
 Stupor & violent behaviour.
 Hysterical attack.
 Withdrawal syndrome.

OTHERS:-
 Over dosage of alcohol or drug.
 Severe depression.
 Delirium.
 Disasters.
 SUICIDE:
 INTRODUCTION:
Suicide is an irrational desire to die or it is
the act of ending your own life. Suicidal
behaviour is a leading cause of injury and
death worldwide.
Each year, approximately
one million people die by suicide
worldwide. It is a major public health
concern. Suicide is tragic. But it is often
preventable. Knowing the risk factors for
suicide and who is at risk can help reduce
the suicide rate. This program is about
suicide. It includes information about who
is at risk, how suicide can be prevented and
what to do if you or someone you know is
considering suicide.
DEFINITION;

“Aggression towards self-following the internalization of

frustration or disappointment related to loved one”.
Freud 1957

‘’ Suicide is the act of deliberately killing oneself. Risk

factors for suicide include mental disorder (such as
depression, personality disorder, alcohol dependence, or
schizophrenia), and some physical illnesses, such as
neurological disorders, cancer, and HIV infection. ’’
World Health Organization
RISK FACTORS :
 Marital status- rate for a single person is twice than
a married person whereas divorced, widowed or
separated have 4-5 times more than those married.
 Gender-women attempt suicide more & men
succeed more often. Successful suicide rate about
70% in male and 30% in female.
 Age-suicide risk and age having positively
correlated among adolescent it has tripled. Elderly it
risen to 25% female suicide decline after 65 yr.
 Socioeconomic status- individual in very highest
&lowest social class have higher suicidal rate than
those in middle class.
Other risk factors-

 Mood disorders
 Mental disorders
 Depressive disorders
 Loss of loved ones
 Lack of employment
 Increased financial burden
 Constant failure to use normal coping mechanism
CAUSES OF SUICIDE:

PSYCHOLOGICAL CAUSES- SOCIAL CAUSES

-Isolated feeling -Physically abused
-loneliness -economic failure
-To solve problems -lack of social support
-Severe frustration -disturbed IPR
-hopelessness & helplessness -Lack of satisfaction
-conflict -social isolation
-stress, threat -low social status
-excessive anger -family problems
-Guilty, shame
-Unfulfilled need
-fear
CLASSIFACTION OF SUICIDE:
 Egoistic suicide- one who has lost social integration with their
social group. It is the response of individual who feels separates
and apart from the main society.
 Altruistic suicide- results from a response of cultural
expectations. The individual is excessively integrated into a
group often governed by cultural, religious, or political ties and
the allegiance is so strong that the individual sacrifice his or her
life for the group, society or for the good of social group.
 Anomic suicide-occurs in response to the changes that occur in
an individual’s life. For example; divorce, loss of jobs.
 Sam sonic suicide or suicide of revenge- to spite others or
experiencing as being unfriendly. For example; if the husband is
unfaithful to his wife, she may attempt to commit suicide to
take revenge from him.
NURSING MANAGEMENT OF
SUICIDAL CLIENT
 ASSESSMENT;

Observable behaviour of client

 depressed, isolated from self
 tense, worried, anxiety, hopelessness
 insomnia, restlessness, fatigue
 acts aggressively, frustrated feelings
 the frequency & extent of suicidal ideas
 feeling associated with suicide
 mental status examination

Once the suicide committed, it is obviously no longer treatable. The

management of suicide therefore lies in preventing the act
 So the prevention of suicide is
PRIMARY PREVENTION-

 Improve skills of team members in identifying high risk client and planning treatment care.
 Never allow high risk to be alone.
 Refer high risk for psychotherapeutic interventions.
 Early recognition & prompt treatment of psychiatric disorders.
 Identify stressors
 Educate community & focus group.
 Modify environment
 Restrict means of suicide.
 Guidance and counselling services.
 SECONDARY PREVENTION-
•Improve availability and quality of help for those who
may be contemplating suicide.
•Arrange for screening high risk cases.
•Organize awareness campaign for resource person
e.g.. Teacher, community leader.
•Establishment of crisis prevention & counselling
centres.
•Provide treatment for actual suicidal crisis in clinics,
and in hospitals.
 TERITARY PREVENTION-
•Interventions with family & friends of person who has
committed suicide e.g.; guidance, psychotherapy,
family therapy.
•Minimizing residual effects of suicidal attempts.
•Follow up & continuity of care has to be planned.
•Supportive system has to be strengthened.
 MANIA

 Manic episodes are periods of extreme elevation of mood

when people feel expansive, energetic, grandiose, and,
sometimes, irritable and ill-tempered. Typical behaviors of
mania are:
 Inflated self-esteem or grandiosity
 Decreased need for sleep (feels rested after only 3 hours of
sleep)
 More talkative than usual or pressured to keep talking
 Subjective experience that thoughts are racing or flight of ideas
 Distractible, attention easily drawn to unimportant or irrelevant
external stimuli
 Intense goal-directed activity, socially, sexually, and
occupationally
 Hyperactive behaviors and symptoms occur in episodes of a
week or more
 Excessive involvement in pleasurable activities with a high
potential for painful consequences, such as unrestrained
buying sprees, foolish business investments, and sexual
indiscretions (DSM-IV-TR, 2000)
 Hypomanic episodes last less than a week and are more
moderate than manic episodes. The symptoms, though
noticeable, are not severe enough to keep the person from
functioning.
 MANAGEMENT
 ASSESSMENT
 Caregivers assess the potential danger of these people in crisis
to themselves and to others and their need for hospitalization.
Often people experiencing a manic episode may not have eaten
or slept for many days and have poor impulse control, resulting
in harm to themselves and others. They may become exhausted
to the point of death.
 Thus, clinicians need to assess the following:
 Medical status, by performing a physical examination
to determine if mania is primary or secondary to a
medical condition or to substance disorder
 Other psychiatric conditions, such as anxiety disorder
and schizoaffective disorder
 Understanding by the client and the family about
bipolar disorder and their knowledge of prescribed
medications, support groups, and organizations
 Nursing Diagnoses
 Because clients exhibit constant and excessive motor activity,
poor judgment, difficulty evaluating reality, probable
dehydration, and lack of impulse control, the following
 NANDA diagnoses may be appropriate: risk for injury, risk for
other-directed violence, risk for self-directed violence, risk for
suicide, ineffective coping, defensive coping.
 Ineffective coping, disturbed thought processes,
impaired verbal communication, impaired social
interaction, imbalanced nutrition, deficient fluid
volume, self-care deficit, and disturbed sleep
pattern .
 PLANNING
 The goal of care for clients in an acute manic episode
is to prevent injury and instill hope for the future.
Therefore, outcome criteria for the client are as
follows:
 Be well hydrated
 Maintain or obtain stable cardiac status
 Maintain or obtain tissue integrity
 Get sufficient sleep and rest
 Demonstrate thought self-control
 Make no attempt at self harm
INTERVENTION

 To meet outcome criteria and ensure safety,

medical stabilization, and external control, people
in crisis manifesting manic symptoms need
hospitalization. If they are not cooperative and are
a danger to themselves or others, emergency
involuntary commitment may be necessary.
 To gain their cooperation and communicate more
effectively, clinicians:
 Use short and concise statements and explanations
 Use a calm but firm approach
 Remain neutral, avoiding power struggles
 Coordinate care with other staff members to avoid
manipulation
 Medications such as antianxiety agents (anti-
anxiolytics), antipsychotics, and antidepressants may
be prescribed. Furthermore, mood stabilizers such as
lithium and valproic acid are considered lifetime
maintenance therapy for bipolar clients. Because the
incidence of substance use disorders is exceptionally
common with bipolar disorder, treatment for mood
disorder and substance abuse should proceed at the
same time when appropriate (APA, 2000).
 VIOLENT OR AGGRESSIVE
BEHAVIOR:

DEFINITION:

It is the severe form of aggression by one individual

to other individual. Violent clients are always not
psychiatrically ill. During this stage, patient will be
irrational, uncooperative and delusional.
RISK FACTORS
DEMOGRAPHIC

•Young age
•Male sex
•Lack of employment
•Limited education
HISTORY

•Violence to self or others

•Antisocial behaviour
•Family violence
•Cruelty or others or to animals
 MEDICAL
•Traumatic brain injury
•Central nervous system dysfunctions
SOCIO-ENVIRONMENTAL
•Financially dependent on family members
•Association with antisocial elements or peer group.

BEHAVIORAL
•Poor impulse control
•Intention to harm self or others
•Antisocial and criminal acts performed
 CAUSES
 Personality disorders, e.g. antisocial behaviour
 Organic psychiatric disorders e.g. delirium, dementia.
 Drug intoxication
 Withdrawal effects of alcohol, drug abuse
 Mental retardation
 Epilepsy
 Domestic violence
 Schizophrenia
 Mania
 Severe depression
 Personality disorders
MANIFESTATIONS

 uncooperativeness
 irrational
 delusions
 feelshumiliated
 Violent or assault behaviour
 NURSING MANAGEMENT
 Minimal stimulating environment (noise or light) and
single room has to be provided close to the nurses’
station for vigilant observation.
 Limit interaction of the client with others.
 Have essential things in the client’s room, avoid sharp
instruments, items, knives, glass pieces, match boxes
etc.
 Avoid keeping hazardous or toxic agents in the
client’s room.
 stay with the client, approach him gently and with
kind, allow
 Cont.….
 stay with the client, approach him gently and with
kind, allow him to talk, encourage him to interact
without any inhibitions, show concern, establish
therapeutic interpersonal relationship etc. all these
factors will enhance security to the client.
 Collect history carefully both from the client and his
support system.
 Carry out complete physical examination to exclude
physical illness.
 Nurse has to follow self-protective measures, when
she is nearer to client.
THE MEASURES WHICH CAN BE ADOPTED TO HANDLE
EXCITED OR VIOLENT BEHAVIOR INCLUDE: -

 REASSURANCE: - in case of emergency, it rarely

works alone but must be tried first.
 SEDATION: -

- Diazepam 5-10 mg parentrally slowly can be given.

- In the presence of psychosis, haloperidol 2-10 mg
parenterally can be given.
 RESTRAINT: - Restraint should always be used a last
resort, but when needed, it should not be delayed.
Restraint should always be done in a humane way, after
taking written consent from the care givers.
 WITHDRAWAL BEHAVIOR
DEFINITION:-

‘’Removed from immediate contact or easy approach,

isolated, unresponsive and socially detached’’.
Webster’s dictionary

OR
‘’An individual tries to avoid social contacts, social
interactions, active participation and involvement in the
social activities due to unpleasant or threatened stressful
situations or unpleasant experiences’’
NURSING MANAGEMNENT:-

 Expertise skills are necessary for nurses in handling

situation.
 Establish therapeutic nurse patient relationship.
 Make the client to understand reality.
 Enhance the social interaction of client with environment
and with family members, relatives and friends.
 Provide opportunity for the client that he can trust the
nurse.
 Record the drug administration.
 Fibre rich diet should be given to the client to prevent
constipation.
Cont.…..
 Serve the client small and frequent feeds.
 Maintain input and output chart.
 Provide calm and safe environment to ensure
sleep.
 Protect the client from self-injury and harm, e.g.
by removing sharp articles besides the client.
 Engage the client to participate in religious
activities, according to interest.
 CATATONIC STUPOR

DEFINITION: -
‘’Stupor is a clinical syndrome of akinesis and
mutism but with relatively preservation of conscious
awareness. Stupor is often associated with catatonic
signs e.g. negativism, echolalia, echopraxia,
stereotypies, mutism etc.’’
Causes of catatonic stupor: -
 Neurological disorders such as cerebral malaria,
surgical procedure on basal ganglia.
 Systemic and metabolic disorders such as diabetic
ketoacidosis, hyperparathyroidism.
 Drugs and poisoning such as aspirin,
antipsychotics, organic alkaloids, lithium toxicity.
 Psychiatric disorders such as depression,
schizophrenia, manic stupor.
MANAGEMENT: -
These steps should be taken-
 Ensure patent airway.
 Check cardiac rhythm.
 Maintain circulation- insert IV line and give fluids.
 Investigations-withdraw blood, CSF and urine
samples before starting any treatment.
 Administer-

-Naloxone 0.4 mg IV (if morphine poisoning is

suspected).
-Hydrocortisone 100 mg IV (if adrenal crisis is
suspected).
 HYSTERICAL ATTACKS

DEFINITION: -

‘’A hysteric may mimic abnormality of any function,

which is under voluntary control’’.
CAUSES:-
 Deprived or abnormal parent child relationship.
 Dissatisfied environment in childhood.
 Broken families.
 impaired social and occupational functioning.
 Hysterical personality, e.g. dramatizing, attention
seeking behaviour.
SYMPTOMS : -
1. SYMPTOMS OF CONVERSION REACTION

 Motor symptoms, (e.g. monoplegia, paraplegia,

paraplegia, quadriplegia etc.). Hyperkinesia (e.g.
tremors, cramps, convulsions etc.).

 Sensory symptoms
- Sensation related to touch, pain, temperature will be
affected.
- Blindness.
-Deafness.
 Visceral symptoms
- Nausea, vomiting, hiccoughs.
-feeling of lumps in throat.
-Dyspnoea
-Aphonia
-Anorexia nervosa
 SYMPTOMS OF DISSOCIATION
-Anxiety
-Desire to escape from stress
-Guiltiness
-Amnesia
 BEHAVIORAL SYMPTOMS

- Low self- esteem

-Self dramatization
-childlike behaviour
-Attention seeking tendency
 NURSING MANAGEMENT
 Provide comfortable environment to the client.
 Show concern, sympathy, and attention with the client.
 Develop therapeutic relationship with the client.
 Record the symptoms expressed by the client.
 Explore the feeling of the client by history collection.
 Assist him to take independent decisions, to identify his role and
responsibilities.
 Give some useful tasks, which he can be able to complete to enhance
his productivity.
 Provide supportive psychotherapy.
 Encourage the client to participate in religious rituals and social
works.
 Encourage the family members to provide love and affection.
ACUTE PSYCHOSIS

 Patients with psychotic symptoms are

common in psychiatric emergency service
settings.

 Thedetermination of the source of the

psychosis can be difficult.
ACUTE PSYCHOSIS or Panic A

 Sometimes patients are brought into the

setting in a psychotic state.

 Psychiatricemergency service setting will

not be able to provide long term care for
patients who have been have been
disconnected from their previous treatment
plan.
 DEFINITION OF PSYCHOSIS:
According to the Diagnostic and Statistical
Manual of Mental Disorders, Fourth
Edition (DSM-IV),

 Psychosis is “disorganized speech, grossly

disorganized or catatonic behavior,
delusions or prominent hallucinations, with
the hallucinations occurring in the absence
of insight into their pathological nature”.
 VIOLENT BEHAVIOR
 Aggression can be the result of both internal and
external factors that create a measurable
activation in the autonomic nervous system.
 Symptoms of aggression:
 Clenching of fists or jaw
 Pacing
 Slamming doors
 Hitting palms of hands with wrists
 Easily startled.
 Violence is also associated with many
conditions
 Acute intoxication

 Acute psychosis paranoid personality disorder

 Antisocial personality disorder

 Narcissistic personality disorder

 Borderline personality disorder.

RISK FACTORS

 Presence of hallucinations & delusions

 Being uneducated
 Prior arrests
 Poor
 Unmarried
 Other neurological impairment,
MANAGEMENT OF VIOLENT PATIENT
 Calmthe patient through empathic, yet firm
verbal means.

 Establish
a collaborative relationship
between patient and the treatment team.

 Appear calm, unthreatened, in control and

to be concerned about your own safety too.
 Example
 When approaching an agitated psychotic patient,
there is always a potential for violence and the
approach should include speaking softly to the
patient in non-judgmental way.

 It is better not to gaze in to the patients' eyes.

 Management of violent patient Contd…..
 A violent patient should not be interviewed alone; at least
one other person should always be present.

 Insituations that are more volatile, the other person

should be a security guard or a police officer.

 Atypical antipsychotics are preferred for agitation in the

setting of primary psychiatric illnesses.
Management of violent patient Contd…..

 Leave the interviewing room's door open

while interviewing the patient.

 The interviewer should have unrestricted

access to an exit by sitting between the
patient and the door.
 Management of violent patient Contd…..
 Make patient clear in a firm, non-angry manner
that they may say or feel anything, but are not
free to act in violent or threatening manner.

 Rapid tranquillization using benzodiazepines and

typical or atypical antipsychotics.
 Carry out complete physical examinations.
 Send blood specimens for hemoglobin, total cell count etc.
 Look for evidence of dehydration and malnutrition. If there is
 severe dehydration, glucose saline drip may be started.
 Have less furniture in the room and remove sharp instruments,
 ropes, glass items, ties, strings, match boxes, etc from patient’s
 vicinity.
 Keep environmental stimuli, such as lighting and noise levels to a
 minimum; assign single room; limit interactions with others.
 Remove hazardous objects and substances; caution the patient
 when there is possibility of an accident.
 · Stay with the patient as hyperactivity increases to reduce anxiety
 level and foster a feeling of security.
Continue………
 Redirect violent behaviour with physical outlets such as
exercise,outdoor activities.
 Encourage the patient to ‘talk out’ his aggressive feelings, rather than
acting them out.
 If the patient is not calmed by talking down and refuses
 medications, restraints may become necessary.
 Following application of restraints, observe patient every 15
 minutes to ensure that nutritional and elimination needs are met.
 Also observe for any numbness, tingling or cyanosis in the
 extremities. It is important to choose the least restrictive
 alternative as far as possible for these patients.
 Guidelines for self-protection when handling an
aggressive patient:
 never see a potentially violent person alone
 keep a comfortable distance away from the patient (arm
length)
 be prepared to move, a violent patient can strike out
suddenly
 maintain a clear exit route for both the staff and patient
 be sure that the patient has no weapons in his possession
before approaching him
 if patient is having a weapon ask him to keep it on a table
or floor
 rather than fighting with him to take it away
 keep something like a pillow, mattress or blanket
wrapped around arm between you and the weapon
 distract the patient momentarily to remove the weapon
(throwing water in the patient’s face, yelling etc)
 give prescribed antipsychotic medications.
 “COMMONLY USED MEDICINES TO
TREAT AGGRESSION”
 Lorazepam:- 2-6 mg/day PO/IM in
divided doses.
 Frequent adverse reaction:-

1. Sedation
2. Dizziness
3. Weakness
4. Unsteadiness
 COMMONLY USED MEDICINES TO
TREAT AGGRESSION
 Inj.Haloperidol:- 2-5 mg every 4-6 hrs.
Frequent adverse reactions:- extra
pyramidal symptoms (EPS).

 Inj.Ziprasidone:- 10-20mg/day.
Maximum 40 mg/day can be given.
 Dosage of 10 mg every 2 hourly and 20 mg
every 4 hourly.
 COMMONLY USED MEDICINES TO
TREAT AGGRESSION
 Risperidone:- 1mg initially bid PO,
increased as tolerated up to 3mg bid.
Frequent adverse reaction:- extra -
pyramidal symptoms.

 Olanzapine:-5-10 mg initially increased

upto 20 mg daily.
 DELIRIUM
 Characterized by :
1. Disturbance of consciousness
2. Change in cognition that develop rapidly over a
short period.

 Duration:- 1 week to 1 month.

 Prodromal symptoms may be sometimes present
like restlessness, difficulty thinking, insomnia &
nightmares.
 PREDISPOSING FACTORS

 Delirium due to general medical conditions

 Substance-induced delirium
 substance-intoxication delirium
 substance-withdrawal delirium
 delirium due to multiple etiologies
 SYMPTOMS OF DELIRIUM

 Difficulty in sustaining and shifting

attention.
 Person is extremely distractible &
repeatedly reminded to focus attention.
 Disorganized thinking.
 Irrelevant, pressured & incoherent speech.
 Switches from one topic to another.
 SYMPTOMS OF DELIRIUM

 Disorientation to time, place and person.

 Disturbance in sleep-wake cycle.
 Agitated, restlessness, hyperactivity and
purposeless movements.
 Emotional instability.
 Illusions and hallucinations.

MANAGEMENT OF DELIRIUM
Environmental manipulation:- to reorient the patient.
Example:-Leaving a light on at night, frequent orientation
to time, place and person.

 Drugs:-
1. Inj. Haloperidol in low doses i.e. 0.5 – 2 mg is frequently
the drug of choice.
2. Lorazepam 0.5 to 2 mg can reduce agitaton and is
preferable in substance withdrawl delirium..
Management:-
 Keep the patient in a quiet and safe environment.
 Maintain fluid and electrolyte balance.
 Reassure patient and family.
 PERSONALITY DISORERS

 Disorders manifesting dysfunction in areas

related to cognition, affectivity,
interpersonal functioning and impulse
control can be considered
personality disorders.

 Patientssuffering from a personality

disorder do not complain about symptoms
usually.

 Considered non-treatable.
 PERSONALITY DISORERS
 Patients suffering an emergency phase of
a personality disorder may show:
1. Suspicious behavior
2. Brief psychotic episodes
3. Delusions.

 Stabilization of the individual to their

baseline level of function.
 ANXIETY
 Patients suffering from an extreme case
of anxiety and seek treatment when they
are unable to bear.

 Causes of anxiety:-
1. Psychiatric disorder.
2. From an underlying medical illness.
 ANXIETY
1. Secondary functional disturbance from another
psychiatric disorder
2. From a primary psychiatric disorder such as
panic disorder or generalized anxiety disorder,
3. A result of stress from such conditions as
adjustment disorder or
post-traumatic stress disorder.
 MANAGEMENT OF ANXIETY

 Firstprovide a "safe harbor" for the patient

so that assessment & treatment can be
given.
 Higher risk of premature death.
 Relaxation exercises.
 Tab. Acetalopram 5-10 mg OD.
SUBSTANCE INTOXICATION AND
WITHDRAWAL
 Resultin acute psychotic symptoms which
resolve after a period of observation or
limited psycho-pharmacological treatment.

The early effects of alcohol are

characterized by:
 Depressant of the central nervous system
 Increased talkativeness
 Giddiness
Early effects of alcohol

 Loosening of social inhibitions.

 Impaired concentration
 Impaired verbal and motor performance,
 Poor Insight & judgment
 Short term memory loss which could result
in behavioral change causing injury or
death.
 Levels of alcohol
 <60milligrams per deciliter of blood are
non-lethal.

 >200 milligrams per deciliter of blood are :

grossly intoxicated.

 =400 milligrams per deciliter of blood are:

lethal, causing complete anesthesia of the
respiratory system.
 Idiosyncratic intoxication
 Occurs in some individuals even after the
consumption of relatively small amounts
of alcohol.

 Chronic alcoholics may also suffer from

alcoholic hallucinosis,

 Cessation of prolonged drinking may

trigger auditory hallucinations for a few
hours or an entire week.
 MANAGEMENT
 Antipsychotics are often used to treat these
symptoms,

 Establish therapeutic rapport to counter denial.

 Determine substances used, route of administration,

dosage, and time of last use to determine the
necessary short and long term treatments.
 MANAGEMENT
 An appropriate choice of treatment setting
must also be determined. Example: out-
patient facilities, partial hospitals, residential
treatment centers, or hospitals.

 Both treatment and setting is determined by

the severity of dependency and seriousness
of physiological complications.
 MANAGEMENT
 Administration
of psychoactive substances
is done. Examples:-

 amphetamine, caffeine, cocaine, opioids

tetrahydrocannabinol, phencyclidines, or
other inhalants,, sedatives, hypnotics,
anxiolytics,
psychedelics, dissociatives and deliriants
 Place
MANAGEMENT
under observation in a secure room away
from stimulation.
 Attempting to talk the patient down is not
recommended.
 Physical restraints or sedation may be necessary
for violent patients.
 Lorazepam 2 to 4 mg stat or diazepam 10 to 20
mg stat is recommended to treat agitation.
 HAZARDOUS DRUG REACTIONS
& INTERACTIONS
 Overdoses, drug interactions, and dangerous
reactions from psychiatric medications,
especially antipsychotics, are considered
psychiatric emergencies.

1. Neuroleptic malignant syndrome

2. Serotonin syndrome
3. Overdose of prescribed psychoactive drugs
 NEUROLEPTIC MALINGNANT
SYNDROME
 It is a potentially lethal complication of
first or second generation antipsychotics.

 It is defined as a hyper metabolic reaction

to dopamine antagonists, primarily
antipsychotic drugs, such as
phenothiazines and butyrophenones.

 It usually occurs early in treatment and

rarely during maintenance treatment.
 CHARACTERISTIC SIGNS OF
(NMS)

 Muscle rigidity
 Hyperpyrexia
 Tachycardia
 Hypertension
 Tachypnea
 Change in mental status
 Autonomic dysfunctions
 MANAGEMENT
 Confirmed by:-
 Respiratory and metabolic acidosis,
myoglobinuria, elevated CK and
leucocytosis.
 Mortality rates are between 10-20%.

 Treatment includes:-
 Cessation of antipsychotic drugs.
 Supportive care
 MANAGEMENT
 Treatment of myoglobinuria, fever and
acidosis.

 The dopamine agonist bromocriptine 2.5 to

20 mg tid or dantrolene up to 10 mg/kg IV
q 4 h may be used as a muscle relaxant.

 Treatment is usually in ICU.

 SEROTONIN SYNDROME
 Result when
selective serotonin reuptake inhibitors or
monoamine oxidase inhibitors mix with
buspirone.

 Severesymptoms of serotonin syndrome

include:

 Hyperthermia
 Delirium
 Tachycardia that may lead to shock.
 SEROTONIN SYNDROME
 Threat
MANAGEMENT
to life apart from intoxication.

 Thepatient should be jointly managed by a

physician and psychiatrist.

 Patientswith severe general medical symptoms,

such as unstable vital signs, should be
transferred to emergency.
 SEROTONIN SYNDROME
 If
MANAGEMENT
the patient has taken a toxic dose and is awake,
then induce emesis followed by administering
activated charcoal.

 Overdose with tricyclic antidepressants or

carbamazepines require cardiac monitoring.

 Overdosages with barbiturates or benzodiazepines

and alcohol may cause respiratory arrest.
DISASTERS
 DISASTERS
 Naturaldisasters and man-made hazards can cause
severe psychological stress in victims surrounding
the event.

The impact of disasters can cause people to be :-

 shocked, overwhelmed, immobilized, panic-

stricken, or confused.
 SYMPTOMS
 Hours, days, months and even years after a
disaster, individuals can experience :-
1. Tormenting memories
2. Vivid nightmares
3. Develop apathy
4. Withdrawal
5. Memory lapses
6. Fatigue, loss of appetite, insomnia, depression,
irritability, panic attacks.
 MANAGEMENT
 Emergency management to help victims
cope with the situation.

 Dependent upon the scale of the disaster,

victims may suffer from both chronic and
acute post-traumatic stress disorder.

 Patientssuffering severely from this

disorder are admitted to psychiatric
hospitals.
 ABUSE
 Physical abuse
 Sexual abuse or rape can cause :-

1. Extreme anxiety & fear

2. Helplessness
3. Confusion
4. Hostility, guilt and shame
5. Eating or sleeping disorders.
 MANAGEMENT
 Coordinate psychological, medical and legal
considerations.
 Report criminal activity to a police force
depending upon legal requirements of
region.
 Gather identifying data during the initial
assessment.
 Refer the patient, if necessary, to receive
medical treatment.
 MANAGEMENT
 Medical treatment:

 Physical examination.
 Collection of medico-legal evidence.
 Determination of the risk of pregnancy, if
applicable.
 STRATEGIES TO PREVENT
ASSAULT
A. Verbal assault:

 Answer all questions softly.

 Be empathic and calm.
 Keep hands visible.
 Keep the door open.
 Stay at least an arm’s length away from
the patient.
 STRATEGIES TO PREVENT
ASSAULT
 Stay to the side of the patient.

 Use non threatening body language.

 Usereflective statements rather than judgmental

ones.
 STRATEGIES TO PREVENT
ASSAULT
(B.)Physical assault:

 Call for help, if possible press the panic

button to summon help.
 Deflect a kick with your legs.
 Deflect punches with your hands.
 Escape.
 STRATEGIES TO PREVENT
ASSAULT
 Face the person sideways.

 If
choked, tuck your chin to the chest to
maintain airway.

 Ifpatient grabs your hair, use your hands to

control the hands of the patient.
 OTHER MANAGEMENT
STRATEGIES

1. Psychotherapy: Brief psychotherapy

2. Electroconvulsive therapy (ECT)

 BRIEF PSYCHOTHERAPY
 Brief psychotherapy can be used to treat acute
conditions or immediate problems as long as the
patient understands his or her issues are
psychological.

 Brief therapy under emergency psychiatric

conditions includes:
1. Establishment of a primary complaint from the
patient.
 BRIEF PSYCHOTHERAPY
1. Realizing psychosocial factors.
2. Formulating an accurate representation of
the problem.
3. Coming up with ways to solve the problem.
4. Setting specific goals.
5. If deeper psychotherapy sessions are
required, the patient is referred to an
appropriate clinic or center.
 (ECT)
Electroconvulsive therapy
ECT is a controversial form of treatment which is
sometimes applied in psychiatric emergency
service settings.

 Usedin severe depressionient with suicidal

attempts and catatonia.

 Research suggests that ECT is an effective

treatment for depression if a course of 6 to 12
ECTs is given.
CONCLUSION
 The increasing incidence of alcohol intake
and drug abuse have lead to an increase
number of patients reporting to the
psychiatry emergency unit.

 It is necessary to be familiar with common

psychiatric emergencies especially suicide
attempts and violent behavior and other
psychiatric emergencies so as to improve
the level of care offered to the patients.
 REFERENCES
 Benjamin J. Sadock, Virginia A. Sadock, Menas
S. Gregory; comprehensive textbook of
psychiatry, 8th edition.

 Roy A. Suicide in; Sadock BJ Sadock VA,

editors. Comprehensive textbook of Psychiatry
7th ed. Lippincott Williams & Wilkins
publishers, 2000; 2031-40.

 www.googles.co.in