Psychiatric emergencies

Mental Health Nursing

1. PSYCHIATRIC EMERGENCY R. RUPPAMERCY, M.Sc NURSING II YEAR, DR. M.G.R EDUCATIONAL & RESEARCH INSTITUTE

2. INTRODUCTION Although we all know when to take our loved ones to the hospital when we see signs of physical illness, the majority of us are entirely unaware of psychiatric conditions . This can be a grave problem in case it is a psychiatric emergency. As compared to a medical emergency, major psychiatric emergencies are different because they can harm the patient and others around them. Situations with significant and severe danger to the patient’s life, to a minor, or to others around them.

3. TERMINOLOGIES An emergency is defined as an unforeseen combination of circumstances which calls for an immediate action. A medical emergency is defined as a medical condition which endangers life and/or causes great suffering to the individual. Psychiatric emergency is a condition wherein the patient has disturbances of thought, affect and psychomotor activity leading to a threat to his existence(suicide), or threat to the people in the environment(homicide). This condition needs immediate intervention to safeguard the life of the patient, bring down the anxiety of the family members and enhance emotional security to others in the environment.

4. DEFINITION Psychiatric emergency might be defined as: A sudden, serious, psychological or psycho-social disturbance which renders the individual unable to cope effectively with his life situation, his interpersonal relationships, and/ or his intrapsychic conflicts . W.J. Cassidy(1967)

5. INITIAL APPROACHES DURING EMERGENCY The initial approach to the patient should be warm, direct and concerned. A quick evaluation to identify the nature of the condition and to institute care on the basis of seriousness is essential. The emergency staff should have basic knowledge of handling psychiatric emergencies. Medico legal cases need to be registered separately and informed to the concerned officer. Hospital security must be adequate to control violent and dangerous patients. History and clinical findings should be recorded clearly in the emergency file. Patient’s condition and plans of management should be explained in simple language to the patient and family members.

6. OBJECTIVES OF PSYCHITRIC EMERGENCY INTERVENTION To safeguard the life of patient To reduce the anxiety To provide the emotional security To educate the client and family members

7. EMERGENCY DEPARTMENT 1. Triage includes assessing the immediate needs of individuals presenting across a variety of priority concerns . two factors must be considered first when triaging the psychiatric patient: medical stability and legal status . The acronym ASSAULTS can assist the nurse to systematically address critical components of an all-encompassing triage evaluation . A - a ssess for all the areas S – s afety S – s uicidality A - a ggressive/assaultive behavior,  U - u nderlying medical conditions , L -   l ethality,  T - t rauma , and S -   s ubstance use/abuse,

8. JOURNAL REFERENCE TITLE - Care of Psychiatric Patients: The Challenge to Emergency Physicians AUTHOR - Leslie Zun , MD, MBA JOURNAL NAME – Western Journal of Emergency Medicine CURRENT ISSUE: VOLUME 17 ISSUE 2 PUBLISHED :  MARCH 2, 2016 The purpose of this article is to discuss disparity and challenges in caring for psychiatric patients. EDs do a good job of determining how to improve the care of the medical patient but they have done little addressing the unique needs of the psychiatric patients. Patient care surveys focus on evaluating the patient care experience of non-psychiatric patients in the ED. These customer service surveys have identified many priorities for patient care and satisfaction in the ED, need for improvement, hence The triage process in the ED is skewed to patients with medical problems over those with psychiatric problems.

9. WESTJEM - Care of Psychiatric Patients: The Challenge to Emergency Physicians

10. RESULT - The author suggests that better treatments protocols are needed for psychiatric patients in crisis in the ED. However, best practices in evaluation and treatment of agitation (BETA) expert guidance recommends that medication be determined by the most probable etiology. Treatment of psychiatric illness should be similarly tailored to the patient and situation. CONCLUSION - It is time to advocate for the psychiatrically ill patient in the ED. We need to push for more training, establishment of standards of care, reduced wait times and find alternatives to boarding.

11. Contd … 2. Safe environment for emergency evaluation Weapon screening Rooms in which the examiner cannot be easily trapped Method to call for help Adequate personnel to respond if help is needed including trained security personnel

12. COMMON PSYCHIATRIC EMERGENCIES 2. VIOLENT/AGGRESSION 1. SUICIDAL ATTEMPT

13. 3. EXCITEMENT 4. PANICK ATTACK

14. 5. CATATONIA 6. WITHDRAWAL SYNDROME

15. 7. HYSTERICAL ATTACKS 8. DELIRIUM TREMENS

16. 9. DYSTONIC REACTION 10. TRANSIENT SITUATIONAL DISTURBANCES

17. 11. ABNORMAL REACTION TO STRESSFUL SITUATION 12. DISASTERS

18. 1. SUICIDE ATTEMPT DEFINITION Suicidal behaviour  includes  suicidal ideation  (frequent thoughts of ending one's life), suicide attempts (the actual event of trying to kill one's self), and completed suicide (death occurs). Suicidal behavior is most often accompanied by intense feelings of hopelessness, depression, or self‐destructive behaviors ( parasuicidal behaviors ). RISK FACTORS Age- adolescent and middle age Gender - women Marital status - unmarried Socio-economic status Occupations – lawyers, dentist, musicians, physicians with F/H

19. CAUSES PSYCHIATRIC DISORDERS Major depression Schizophrenia Drug/ alcohol abuse Dementia Delirium Personality disorder PHYSICAL DISORDERS Cancer Arthritis AIDS PSYCHOSOCIAL FACTORS Failure in examination Dowry harassment Marital problem, Loss of loved Isolation Alienation from social groups Financial and occupational difficulties

20. MANAGEMENT Assessing suicidal risk MSE Psychopharmacological Treatment NURSING MANAGEMENT Assessing the suicidal risk/potential. Mental status examination. Monitor the patient’s safety needs- Search for toxic agents such as drugs or alcohol. Do not leave the drug tray within the reach of the p atient . Make sure that daily medication is swallowed. remove sharp instruments, straps, belts etc. Do not allow the patient to bolt the door on inside, make sure that somebody accompanies him to the bathroom.

21. Contd … Patient should be kept in constant observation and should be never left alone. Spend time with him, talk to him, and allow him to ventilate his feelings. Encourage him to talk about his suicidal plans/methods. If suicidal tendency are very severe, sedate the patient. A ‘no suicidal’ pact may be signed. Enhance self esteem of the patient by focusing on his strengths rather than weaknesses.

22. PREVENTION One to one relationship Assess suicidal risk daily Remove hazardous objects Window locked Monitor patient Be alert of verbal and non-verbal clues Verbal and written contracts Problem solving techniques Place near nurses station Do not allow to bolt the door

23. Measures in case of attempted suicide Do not panic/ raise an alarm Act with speed and coordination Emergency medical measures-check pulse, respiration and airway - if overdose of medicine- gastric lavage -Turn head to one side - pulse- inj. Decadron 4mg IV Plan intervention to control future attempts.

24. 2. VIOLENT/AGGRESSION DEFINITION Social psychologists define aggression as behavior that is intended to harm another individual who does not wish to be harmed. (Baron & Richardson, 1994) Violence is defined as “a physical act of force intended to cause harm to a person or an object and to convey the message that the perpetrator’s point of view is correct and not the victim’s.” (Harper- Jaques and Reimer, 1992 )

25. ETIOLOGY Personality disorder Organic psychiatric disorder Drug intoxication Panic disorder Acute stress reaction Psychotic disorder

26. SIGNS AND SYMPTOMS IN TRIGGERING PHASE- Restlessness Anxiety Irritability Muscle tension Rapid breathing Perspiration Loud voice. IN ESCALATION PHASE- Pale or flushed face Yelling Agitated Threatening Demanding Clenched fists Hostility , loss of ability to solve problems. IN CRISIS PHASE- Loss of emotional and physical control Throwing objects Kicking , Hitting Spitting Biting , scratching Screaming Inability to communicate clearly. IN RECOVERY PHASE- Lowering of voice Decreased muscle tension Clearer More rational communication and Physical relaxation . IN POST CRISIS PHASE- Remorse Apologies Crying Quiet Withdrawn behavior .

27. MANAGEMENT Talk Food Medications Physical restraints Support NURSING INTERVENTION Decreased environmental stimuli Limit interaction with others Stay with patient Gentle approach Create safe environment Maintain clear exit Do not keep provocative members Redirect violent behaviour Talk out rather acting out

28. 3. PANIC ATTACK DEFINITION Panic attack: Is a brief period of extreme distress, anxiety, or fear that begins suddenly and is accompanied by physical and/or emotional symptoms. • Panic disorder: Is involves spontaneous panic attacks that occur repeatedly, worry about future attacks, and changes in behavior to avoid situations that are associated with an attack. Episodes of acute anxiety and panic can occur as a part of psychotic or neurotic illness. The patient will experience palpitations, sweating tremors, feelings of choking, chest pain, nausea. abdominal distress, fear of dying, parasthesia , chills or hot flushes

29. CAUSES Neurochemical dysfunction Genetic hypothesis Cognitive dysfunction

30. SIGNS AND SYMPTOMS Signs and symptoms Palpitation sweating Tremors Feeling of choking Chest pain Nausea Abdominal pain Chills Fear of dying

31. MANAGEMENT Give reassurance Search for causes Diazepam 10mg/ lorazepam 2mg NURSING MANAGEMENT Develop trust relationship through communicating core communication values(caring, acceptance, empathy) Stay with the client and offer reassurance of safety and security Maintain a calm non threatening environment Help client recognize early signs

32. 4. CATATONIC STUPOR DEFINITION Stupor is a clinical syndrome of akinesis and mutism but with relative preservation of conscious awareness. Stupor is often associated with catatonic signs and symptoms . The various catatonic signs include mutism , negativism, stupor, ambitendency , echolalia, echopraxia , automatic obedience, posturing, mannerisms, stenotypes, etc., 

33. SIGNS AND SYMPTOMS Akinesia and mutism ( conscious awareness) Signs: Mutism Negativism Stupor Ambitendency Echolalia Echopraxia Automatic obedience Posturing Mannerism

34. MANAGEMENT Maintain hydration Check vitals Keep airway patent Ventilator support Personal hygiene Identify specific cause and threat NURSING MANAGEMENT Collect history and perform physical examination . Ensure patent airway . Administer iv fluids . Draw blood for investigations before starting any treatment . Care of skin, nutrition and personal hygiene.

35. 5. EXCITEMENT Excitement is a general psychomotor over activity i.e. excessive motor and psychic activity leading to behavior disorder, where the behavior disorder, where the patient may hurt himself and/or others. Etiology 1. Psychosocial disorder 2. organic disorder – Delirium, Dementia 3. Substance abuse – intake of stimulant eg . Cocain , alcohol or during the withdrawal period

36. MANAGEMENT Remove chains and restrains Talk Sedate Take history Physical examination Send blood for Hb ,WBC,ESR,RBC etc Treat hydration Retain limited furniture Provide safe environment

37. NURSING MANAGEMENT Collect history and perform physical examination Administer IV fluids Ensure patent airway Draw blood for investigations before starting my treatment Other care is same as that for an unconscious patient.

38. 6. HYSTERIAL ATTACKS(DISSOCIATIVE DISORDER) DEFINITION An uncontrollable outburst of emotions or fear, often characterized by irrationality, laughter, weeping etc. A hysteric may mimic abnormality of any function, which is under voluntary control. The common modes of presentation may be: Hysterical fits Hysterical ataxia Hysterical paraplegia Marked by dramatic Quality & sadness of mood

39. Contd.. It is a attention seeking behavior, repressed anxiety, tranformation of an unconscious conflict in to physical symptoms, such as paralysis, blindness, loss of sensation etc. MANAGEMENT  Hysterical fits are distinguish from true / genuine fits • Explain the psychological nature of disease to the relatives of the patient • Reassure the family members that no harm would come to pt. • Help the pt to recognize the meaning of symptoms & identify suitable alternative coping mechanism • Observe the patient continuously • Suggestion therapy with IV pentothal, helpful in some cases.

40. NURSING MANAGEMENT Identify primary and secondary gains . Do not focus on the disability; encourage the patient to perform self care activities as independently as possible. Intervene only when patient requires assistance. Do not allow the patient to use the disability as a manipulative tool to avoid participation in therapeutic activities. Withdraw attention if patient continues to focus on physical limitations . Encourage patient to verbalize fears and anxieties . Identify specific conflicts that remain unresolved and assist patient to identify possible solutions . Assist the patient to set realistic goals for the future . Help the patient to identify the areas of life situation that are not within his ability to control.

41. 7.DYSTONIC REACTIONS An idiopathic reaction to major transquilizers and related drugs such as phenothiazanes ( compazine , prochlorperazine ), Haloperidol, metaclopramide etc. consisting of abnormal muscle contractions. Can occur after single, first time dose or in patients who have had the same medicine before without problem.

42. MANAGEMENT Promethazine 25-50 mg Diphenhydramine 25-50 IM/IV Biperdone 2-3 mg/IM Diazepam 5-10 mg IM/IV slowly No response after 3 doses-suspect other diseases . NURSING MANAGEMENT Administer medication and assess for effectiveness.

43. 8. TRANSIENT SITUATIONAL DISTURBANCES These are characterized by disturbed feelings and behaviour occurring due to overwhelming external stimuli . The symptoms include depression, fatigue, sadness, cruing spills, anxiety, poor concentration, social withdrawal etc.

44. CONTD… Management: Reassurance Mild sedation if necessary Allowing the patient to ventilate his/her feelings Counseling by an understanding professional NURSING MANAGEMENT Presence, support, reassurance as well as the bond with the family are cornerstones of the nursing care.

45. 9. DELIRIUM TREMENS Delirium tremens is a potential form of ethanol(alcohol) withdrawal. Symptoms: may begin a few hours after the cessation of ethanol, but may not peak until 48 – 72 hours. Altered mental status – confusion, hallucinations, service agitation or generalized seizures – 6 – 48 hours after last drink. Tremors Irritability Insomnia Nausea/vomiting Hallucinations, delusions Severe agitation

46. MANAGEMENT Safe environment Sedation Diazepam 10mg/ Lorazepam 4mg IV Fluid and electrolyte balance Reassurance NURSING MANAGEMENT Monitor vital signs, observe the patient carefully . Decrease stimulation, provide a quiet and safe environment. Evaluate the patients hydration and serum electrolytes. Maintain I/O chart. Administer IV fluids. Carefully evaluate the patient for presence of other concomitant medical or surgical problems like trauma, GI bleed etc.

47. CONTD… Observe for the development of possible focal neurological sign . Institute high calorie and high carbohydrate diet . Add thiamine 100 mg IM, then orally, folic acid 1 mg orally daily for 7 – 10 days . Infections, that is, aspiration pneumonia should be suspected and treated. Reassure patient and family.

48. EPILEPTIC FUROR Following epileptic attack patient may behave in a strange manner and become excited and violent . After attack Patients becomes excited and violent Management : Inj. Diazepam 10mg Haloperidol 10mg IV Inj. Luminal 10mg followed by oral anticonvulsant

49. 10. WITHDRAWAL SYNDROME Withdrawal from drugs and alcohol is a common  psychiatric emergencies and the substances such as Alcohol Opioids Barbiturates and Benzodiazepine Stimulants - Cocaine and amphetamines SIGNS AND SYMPTOMS More severe symptoms such as hallucinations, seizures, delirium may also occur in some instances . Changes in appetite, Changes in mood, Congestion, Fatigue, Irritability, Muscle pain, Nausea, Restlessness, Runny nose, Shakiness, Sleeping difficulties, Sweating, Tremors, Vomiting etc.

50. MANAGEMENT Patients should be monitored regularly (3-4 times daily) for symptoms and complications. Patients should drink at least 2-3 litres of water per day during withdrawal to replace fluids lost through perspiration and diarrhoea . Also provide vitamin B and vitamin C supplements . The dose must be reviewed on daily basis and adjusted based upon how well the symptoms are controlled and the presence of side effects Symptomatic medications should be offered as required for aches, anxiety and other symptoms .  psychological therapy that focuses on providing patients with skills to reduce the risk of relapse. Patients in withdrawal should  not  be forced to do physical exercis

51. 11. ABNORMAL REACTION TO STRESSFUL EVENTS The response to stressful events has three components: 1 . an emotional response, with somatic accompaniments 2 . a coping strategy 3 . a defence mechanism.

52. PTSD This is a prolonged and abnormal response to exceptionally intense stressful circumstances such as a natural disaster or a sexual or other physical assault . MANAGEMENT  Comfort and consolation • Protection from further threat and distress • Immediate physical care • Helping reunion with loved ones • Sharing the experience (but not forced) • Linking survivors with sources of support • Facilitating a sense of being in control • Identifying those who need further help (triage) • facts—the victim relates what happened • thoughts—they describe their thoughts immediately after the incident • feelings—they recall the emotions associated with the incident • assessment—they take stock of their responses • education—the counsellor offers information about stress responses and how to manage them .

53. 12. DISASTER Victims of disaster are people, who have survived a sudden, unexpected , overwhelming stress. This is beyond normally what is expected in life, like in and earthquake , flood, riots and terrorism, Anger, frustration, guilt, numbness and confusion are common features in these people. Management: Treatment for life threatening physical problems Critical Incident Debriefing (CID) is a special technique, which is used to lessen the discomfort of the disaster victims.

54. CRITICAL INCIDENT TECHNIQUE

55. Critical incident debriefing includes five phases: Fact, thought, reaction, reaching and Re-entry In the fact phase, each participant is involved to share his or her perception of the incident.The group members describe the incident, new information and pieces of information are integrated into a more understandable whole. The thought phase, builds on this information by asking participants to reflect the incident and to share what they were feeling personally during different times of the crisis. 

56. CONTD.. In the reaction phase, participants are asked to evaluate the impact of the emotional aspects of the incident (for example, what was the worst part of the incident for you). Knowing that other people are experiencing the same feelings makes them realize that these feelings are normal behavioural responses to abnormal circumstances, and this brings a lot of relief to people who are under intense stress. Participants discuss stress related symptoms they had during the incident or are experiencing currently . The teaching phase, focuses on specific cognitive, emotional and spiritual strategies to reduce stress and ways to enhance group support. In the final re-entry phase, the facilitator encourages questions and summarizes the process, Finally individuals are referred to further counseling if needed.

57. RAPE VICTIM Rape is a perpetuation of an act of sexual inter- course with a female against her will and consent. SIGNS & SYMPTOMS: Acute disorganization characterized by self blame, fear of being killed, feeling of degradation and loss of self esteem, feelings of depersonalization and derealisation recurrent intrusive thoughts, anxiety and depression are commonly seen. Long term psychological effects like post traumatic stress disorders (PTSD) can occur in some cases. 

58. MANAGEMENT Be Supportive, reassuring and non – judgmental. Physical examination for any injuries. Give morning after pill to prevent possible pregnancy. Send samples for STD & HIV infection. Explain to the patient the possibility of PTSD, sexual problems like vaginismus and anorgasmia which may appear later

59. JOURNAL REFERENCE TITLE - Psychiatric Illness in the Emergency Department AUTHOR – Ali Madeeh , kim – lan , qammar , samia JOURNAL NAME – Psychiatric annals Psychiatric Illness in the Emergency Department PUBLISHED – January 2018 VOLUME – 48(1 ): 21-27 ISSUE NO - 1

60. ABSTRACT A substantial number of patients with mental illness present to emergency departments (EDs) for treatment, and their numbers are continuing to rise . Patients with substance use disorders are the most common , but there are also patients with suicidal ideation or those who have al-ready attempted suicide, as well as patients with psychosis, altered mental status , and acute anxiety disorders. Among patients with substance use disorders, “ traditional” drugs of abuse ( ie , alcohol, marijuana , cocaine) continue to predominate , but there is an increasing number of patients who present with intoxication caused by “designer” drugs, which are much harder to detect. Suicide attempts remain a leading cause of ED presentation and require ED personnel to not just do triage and in-depth assessment, but also to make recommendations for adequate follow-up .

61. CONCLUSION Substance use disorders including newer “ designer” drugs that are hard to detect continue to pose a challenge to ED physicians. ED physicians , including psychiatrists and mental health workers who work in EDs, need to be vigilant for patients who may present to EDs with these disorders. Appropriate triage, rapid but comprehensive evaluation , appropriate management , and timely referrals for after care ensure the best possible outcomes.

62. CONCLUSION A psychiatric emergency is any unusual behavior, mood, or thought, which if not rapidly attended to may result in harm to a patient or others. The incidence of alcohol and substance abuse in our country as well as the rise in levels of unipolar depression, have led to an increased number of patients reporting to the emergency care unit. It is necessary to be familiar with common psychiatric emergencies especially suicide attempts and violent behaviour and other psychiatric emergencies so as to improve the level of care offered to the patients

63. THANK YOU…….