Psychiatric emergency

Almost all people affected by emergencies will experience psychological distress which for most people will improve over time.People with severe mental disorder are especially vulnerable during emergencies and need access to mental health care and other basic needs.

1. BHARATI VIDYAPEETH (DEEMED TO BE UNIVERSITY) COLLEGE OF NURSING, PUNE PRACTICE TEACHING ON PSYCHIATRIC EMERGENCIES BY, MS SHWETA GODSE

2. OBJECTIVES Define psychiatric emergencies. Discuss history of psychiatric emergencies. Enlist the common psychiatric emergencies. Explain the objectives of psychiatric emergencies Discuss the characteristics of psychiatric emergencies Explain the management of psychiatric emergencies.

3. INTRODUCTION 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 emergencies are acute changes in behavior that negatively impact a patient's ability to function in his or her environment. Often such patients are in a state of crisis in which their baseline coping mechanisms have been overwhelmed by real or perceived circumstances.  

5. 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

6. CHARACTERISTICS OF PSYCHITRIC EMERGENCIES Unable to cope with the stressful situation or family in handling the stressors. Sudden unexpected disorganization in person.

7. Disharmony between client and his environment. Certain condition or stressor predisposes the client family members to seek immediate intervention as they feel more discomfort.  

8. SUICIDAL THREAT

9. DEFINITION Suicide   is   defined   as   the   intentional   taking   of   one's   own   life . OR Suicide is a type of deliberate self-harm and is defined as an intentional human act of killing oneself.

10. ETIOLOGY 1) Psychiatric Disorders Major depression Schizophrenia Drug or alcohol abuse Dementia Delirium Personality disorder 2) Physical Disorders Patients with incurable or painful physical disorders like, cancer and AIDS.

11. Psychosocial Factors Failure in examination Dowry difficulties Loss of loved object Marital difficulties Isolation and alienation Financial and from social groups occupational difficulties

12. RISK FACTORS FOR SUICIDE Age Males above 40years of age Females above 55years of age Gender Men have greater risk of completed suicide. Suicide is 3 times more common in men than in women. women have higher rate of attempted suicide Being unmarried, divorced, widowed or separated Having a definite suicidal plan History of previous suicidal attempts Recent losses

13. SUICIDAL TENDENCY IN PSYCHIATRIC WARDS Major depression Schizophrenia Mania Drug or alcohol abuse Personality disorder Organic conditions

14. MANAGEMENT Be aware of certain signs which may indicate that the individual may commit suicide, such as: • Suicidal threat • Writing farewell letters • Giving away treasured articles making a will Closing bank accounts Appearing peaceful and happy after a period of depression • Refusing to eat or drink, maintain personal hygiene.

15. 2. Monitoring the patient's safety needs: • Take all suicidal threats or attempts seriously and notify psychiatrist • Search for toxic agents such as drugs/ alcohol • Do not leave the drug tray within reach of the patient, make sure that the daily medication is swallowed • Remove sharp instruments such as razor blades, knives, glass bottles from his environment. .

16. • Remove straps and clothing such as belts, neckties. • Do not allow the patient to lock his door on the inside, make sure that somebody accompanies him to the bathroom. • Patient should be kept in constant observation and should never be left alone • Have good vigilance especially during morning hours.

17. Spend time with him, talk to him, and allow him to ventilate his feelings. Encourage him to talk about his suicidal plans I methods • If suicidal tendencies are very severe, sedation should be given as prescribed

18. 3. Encourage verbal communication of suicidal ideas as well as his/her fear and depressive thoughts. 4. Enhance self-esteem of the patient by focusing on his strengths rather than weaknesses.

19. VIOLENT OR AGGRESSIVE BEHAVIOR OR EXCITEMENT

20. This is a severe form of aggressiveness. During this stage, patient will be irrational, uncooperative, delusional and assaultive.

21. ETIOLOGY • Organic psychiatric disorders like, delirium, dementia Other psychiatric disorders like, schizophrenia, mania, agitated depression, withdrawal from alcohol and drugs, epilepsy, acute stress reaction, panic disorder and personality disorders. .

22. MANAGEMENT • Restrain the patient.   Physical – Chemical   • Talk to the patient and see if he responds. • Usually sedation is given. Common drugs used are: diazepam 10-20mg, IV;haloperidol 10-20mg; chlorpromazine 50-100mg IM. Once the patient is sedated, take careful history from relatives. In particular check for history of convulsions, fever, recent intake of alcohol, fluctuations of consciousness.

23. Carry out complete physical examination. • Have less furniture in the room and remove sharp instruments, ropes, glass items, ties, strings, match boxes, etc. from patient's vicinity. • Stay with the patient as hyperactivity increases to reduce anxiety level and foster a feeling of security. • Redirect violent behavior 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 medication, restraints may become necessary.

24. 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. Give prescribed antipsychotic medications.

25. PANIC ATTACKS

26. 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 2 mg may be administered

27. CATATONIC STUPOR

28. Stupor is a clinical syndrome of akinesis and mutism but with relative preservation of conscious awareness. The various catatonic signs include mutism, negativism, stupor, ambitendency , echolalia,echopraxia , automatic obedience, posturing, mannerisms, stereotypies , etc.

29. MANAGEMENT • Ensure patent airway • Administer IV fluids • Collect history and perform physical examination • Draw blood for investigations before starting any treatment

30. HYSTERICAL ATTACKS

31. Hysterical means  "marked by uncontrollable, extreme emotion." A hysteric may mimic abnormality of any function, which is under voluntary control. The common modes of presentation may be . • Hysterical fits • Hysterical ataxia ( inability to coordinate limb movements • Hysterical paraplegia All presentations are marked by a dramatic quality and sadness of mood.

32. 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. • Help the patient realize the meaning of symptoms, and help him find alternative ways of coping with stress. • Suggestion therapy with IVpentothal may be helpful in some cases.

33. 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 • Counseling by an understanding professional

34. ORGANIC PSYCHIATRIC EMERGENCIES Delirium tremens Epileptic furor Acute drug-induced syndrome Drug toxicity Extra pyramidal

35. 1) DELIRIUM TREMENS Delirium tremens is an acute condition resulting from withdrawal of alcohol. MANAGEMENT • Keep the patient in a quiet and safe environment. • Sedation is usually given with diazepam 10mg or lorazepam 4 mg IV,followed by oral administration. • Maintain fluid and electrolyte balance. • Reassure patient and family.

36. 2) EPILEPTIC FUROR Following epileptic attack patient may behave in a strange manner and become excited and violent. MANAGEMENT • Sedation – Inj. Diazepam 10 mg IV – Inj. Haloperidol 10 mg IV IV followed by oral anticonvulsants. • Haloperidol 10 mg IV helps to reduce psychotic behaviour.

37. 3) ACUTE DRUG-INDUCED EXTRAPYRAMIDAL SYNDROME Antipsychotics can cause a variety of movement related side-effects, collectively known as Extra Pyramidal Syndrome (EPS). Neuroleptic malignant syndrome is rare but most serious of these symptoms and occurs in a small minority of patients taking neuroleptics , especially high potencycompounds .

38. MANAGEMENT The drug should be stopped immediately. Cool the patients body temperature Maintain Fluid and electrolyte balance Diazepam for muscle relaxation Dantrolene to treat malignant hyperthermia

39. 4) DRUG TOXICITY Drug over-dosage may be accidental or suicidal. In either case all attempts must be made to find out the drug consumed. A detailed history should be collected and symptomatic treatment instituted.

40. A common case of drug poisoning is lithium toxicity. The symptoms include drowsiness,vomiting , abdominal pain, confusion, blurredvision , acute circulatory failure, stupor and coma,generalized convulsions, oliguria and death.

41. MANAGEMENT • Administer 02 • Start IV line • Assess for cardiac arrhythmias • Refer for hemodialysis Administer anticonvulsants.

42. RAPE / SEXUAL ASSULT DEFINITION Unlawful sexual activity and usually sexual intercourse carried out forcibly or under threat of injury against a person's will or with a person who is beneath a certain age or incapable of valid consent because of mental illness, mental deficiency, intoxication, unconsciousness, or deception.

43. 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.

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

45. VICTIMS OF DISASTER Victims of disaster are people, who have survived a sudden, unexpected, overwhelming stress. EXAMPLE:- Earthquake, flood, riots and terrorism S/S :- Anger, frustration, guilt, numbness and confusion are common features in these people.

46. MANAGEMENT Treatment for life threatening physical problems Group therapy In selected cases benzodiazepines are prescribed to reduce anxiety and induce sleep. Educate the victims that these emotional reactions are normal reactions to an extraordinary and abnormal situation, and are to be expected under the circumstances. Educate about the available services. Referral to mental health service, if required Teach coping strategies to avoid the development of the crises. For example, strategies to be taught can include how to request information, access resources and obtain support.

47. SUMMARY Today we have seen definition, history, objectives, characteristics of psychiatric emergencies and common psychiatric emergencies and their management.

48. CONCUSION The increasing 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 for all clinicians 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.

49. BIBLIOGRAPHY R Sreevani , A guide to Mental Health and Psychiatrics Nursing, Jaypee Brothers 4 th edition, page no 305 KP Neeraja , Essentials of Mental Health and Psychiatric Nursing, Volume two, Jaypee, Page No 304 - 335 Niraj Ahuja , A short textbook of psychiatry, 6 th edition, Jaypee, page No. 235 http://emed.ie/Psychiatry/Emergencies.php https://www.slideshare.net/ https://medical-dictionary.thefreedictionary.com/suicide