Psychiatric emergencies

A clinical application of psychiatry in emergency setting.

1. Psychiatric Emergencies Awaneet Madan P.B.Bsc. II nd Year ECON

2. Introduction Clinical application of psychiatry in emergency setting is stated as Psychiatric Emergency. Conditions requiring psychiatric interventions may include attempted suicide, substance abuse, depression, psychosis, violence or other rapid changes in behavior. Psychiatric emergency services are rendered by professionals in the fields of medicine, nursing, psychology and social work.

3. Definition A condition where the patient has disturbance of thoughts, affect and psychomotor activity leads to a threat to his existence or to the people in the environment is called psychiatric emergency.

4. Characteristics Any condition or situation making the patient and relatives to seek immediate treatement Disharmony between subject and environment Sudden disorganization in personality which affects the socio-occupational functioning

5. General Guidelines Handle with the utmost of tact and speech so that well being of other patients is not affected. Act in a calm and coordinate manner Shift the client as soon as possible to a room to prevent injury. Ensure that the all other clients are reassured and their routine activities proceed normally.

6. Types of Psychiatric Emergencies Suicide Violence or excitement Stupor & Catatonic Syndrome Panic Hysterical attacks Transient situational disturbances Epileptic furor Acute drug induced extrapyramidal syndrome

7. Drug toxicity Victims of disaster Rape Victims

8. 1 . Suicide (commonest) Deliberate self harm An intentional human act of killing oneself Etiology: Psychiatric Disorders – Major depression, schizophrenia, drug or alcohol abuse, dimentia, dilirium, personality Disorders. Physical Disorders – Incurable or painful physical disorders(Cancer, AIDS) Psychosocial Factors – Examination Failure, Dowry Harassment, marital problems, loss of loved ones, isolation from social groups, financial and occupational difficulties.

9. Risk Factors for suicide: Age – Male above 40 years of age, Females above 50 years of age. Sex – Men > Women Recent losses Being unmarried, divorced, widowed or separated. Management: Be aware of certain signs which may indicate that the individual may commit suicide. Monitoring the patient’s safety need. Do not allow the patient to bolt his door on the inside. Encourage verbal communication of suicidal ideas. Enhance self esteem of the patient.

10. 2. Violent or aggresive behaviour or excitement. This is a severe form of aggressiveness. Patient will be irrational, uncooperative, delusional and assualtive. Etiology: Organic psychiatric disorders(Delirium, dimentia, Wernicke-Korsakoff’s psychosis) Other psychiatric disorders ( Schizophrenia, Mania, Agitated depression, Withdrawal from alcohol and drugs, Epilepsy, Acute stress reaction, Panic disorder and personality disorders.

11. Management : An excited patient is usually brought tied up with rope or in chains. The first step should be to remove the chains. A large proportion of aggression and violence is due to the patient feeling humiliated at being tied up in this manner. Talk to the patient and see if he responds. Firm and kind approach by the nurse is essential. Usually sedation is given. Common drugs used are: diazepam 10-20mg IV; haloperidol 10-20mg, chlorpromazine 50-100mg IM. Once the patient is sedated, collect history carefully from relatives, rule out the possibility of organic pathology. Carry out complete physical examination.

12. Send blood specimens for haemoglobin, total cell count, etc. Look for evidence of dehydration and malnutrition. Have less furniture in the room and remove sharp instruments. Remove hazardous objects and substances; caution the patient when there is possibility of an accident. Guidelines 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 kove, a violent patient can strike out suddenly. Maintain a clear exit route for both the staff and patient.

13. 3. Panic attacks: 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, paresthesias, chills or hot flushes. Management- Give reassurance first Search for causes Diazepam 10mg or lorazepam 2mg maybe administered.

14. 4. STUPOR & CATATONIC SYNDROME Stupor- A clinical syndrome of akinesis & mutism with relative preservation of conscious awareness. Catatonic Syndrome- Any disorder which presents with at least 2 catatonic signs. CATATONIA- either excited/withdrawn CATATONIC- Negativism, mutism, stupor, ambitendency, echolalia, echopraxia, etc...

15. Management- Ensure patent airway. Collect history and perform physical examination. Draw blood for investigation before starting any treatment. Other care is same as that for an unconscious patient.

16. 5. HYSTERICAL ATTACKS: 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 All presentations are marked by a dramatic quality and sadness of mood. Management- Hysterical fit must be distinguished from genuine fits. As hysterical symptoms can cause panic among relatives, explain to the relatives the psychological nature of symptoms. Reassure that no harm would come to the patient.

17. 6. TRANSIENT SITUATIONAL DISTURBANCES These are characterized by disturbed feelings and behavior occurring due to overwhelming external stimuli. Management- Reassurance Mild sedation if necessary Allowing the patient to ventilate his/her feelings Counselling by aN understanding professional

18. 7. DELIRIUM TREMENS Delirium Tremens is an acute condition resulting from withdrawal of alcohol. MANAGEMENT- Keep the patient ina quiet and safe environment. Sedation is usually given with diazepam 10mg or Lorazepam 4mg IV, followed by oral administration. Maintain fluid and electrolyte balance. Reassure patient and family.

19. 8. EPILEPTIC FUROR Following epiletic attack patient may behave in a strange manner and become excited and violent. MANAGEMENT – Sedation: Inj. Diazepam 10 mg IV or Inj. Luminal 10 mg IV followed by oral anticonvulsants. Haloperidol 10 mg IV helps to reduce psychotic behavior.

20. 9. ACUTE DRUG-INDUCED EXTRAPYRAMIDAL SYNDROME Antipsychotics can cause a variety of movement related side effects, collectively known as Extra Pyramidal Syndrome (EPS). MANAGEMENT- Stop the drug immediately. Only symptomatic treatment is left. Cool down the patient Maintain fluid electrolyte balance Treating intercurrent infections. Diazepam for muscle stiffness.

21. 10. DRUG TOXICITY- Drug overdose maybe accidental or suicidal. Attempts must be made to find out the drug consumed. A detailed history should be collected and symptomatic treatment is instituted. Common cause of drug poisoning is lithium toxicity. MANAGEMENT- Administer Oxygen Start IV line Assess for cardiac arrhythmias Refer for hemodialysis

22. 11. VICTIMS OF DISASTER People who have survived a sudden, unexpected, overwhelming stress. This is beyond normally what is expected in life, like an earthquake, flood, riots and terrorism. Anger, frustration, guilt, numbness and confusion are common features in these people. MANAGEMENT- Treatment for life threatening physical problems CID Group therapy Benzodiazepines for anxiety cases

23. 12. RAPE VICTIMS A perpetuation of an act of sexual intercourse with a female against her will and consent is rape. SIGN AND SYMPTOMS- Acute disorganization Self blame Derealization PTSD MANAGEMENT- Be supportive, reassuring and non judgemental Physical examination for any injury Send samples for STD and HIV

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