Psychiatric Emergencies Students

Psychiatric Emergencies Dr. Adel Ahmed Alzayed Kuwait university – Medical college Department of Psychiatry 

  

    To

be able to describe the common types and causes of psychiatric emergencies.



 To

be able to describe acute management of common psychiatric emergencies.

Objectives

     History 

 Collateral

history



◦ Is it a chronic problem? Crisis ? Why now? are the expectations?

General assessment

What

  Physical

examination



◦ Uncooperative agitated inappropriate patients tend to aggravate staff and lead to inadequate medical care and not be examined properly. 

General assessment

   Mental

state examination



Investigation

- Laboratory – screens- Imaging



General assessment



  Aims ◦ Engagement ◦ Assess future risk ◦ Identify risk factors for harm (especially modifiable maintaining factors ) ◦ Create management plan ◦ Understand the patients wish to die ◦ Diagnose psychiatric disorder if present

Assessment of the suicidal

   S ­ Sex

 A ­ Age

 D­ Depression

 P ­ Psychiatric care

 E ­ Excessive drug use

 R ­ Rational thinking absent  S ­ Single

 O ­ Organized attempt

 N ­ No supports (isolated)  S ­ States future intent

Risk factors for suicide



Not

just psychiatric disorders (although commonest cause).



Numerous

“non-psychiatric” causes



Needs

full medical/psychiatric work up



High

dose benzodiazepines/ECT

Catatonia/Mute

   Agitation

is excessive motor or verbal activity.



 Common

examples include:



◦ ◦ ◦ ◦ ◦

hyperactivity verbal abuse threatening gestures and language physical destructiveness vocal outbursts



Agitation



 Commonest

violence:

psychiatric disorders that present with

◦ psychotic disorders (schizophrenia, mania, paranoid states,+/-hallucinations), ◦ drug abuse ◦ alcohol abuse 

 Of

violent people with schizophrenia 71% are substance abusers (12 times risk violence).



 Organic

brain syndromes (7-28%)

Violent Patient

 Ensure

safety of patient and staff.



To

determine if ideation or behavior stems from specific psychiatric illness.



Warn

third parties of a serious threat of harm is present.



To

draw an effective and appropriate treatment plan.

Violent Patient



Remove

potential weapons e.g. keys, chairs.



Get

other patients to safe place.



Put

patient in quiet setting, reduce stimulation.



Attitude

- nonjudgmental, calm, helpful, slow, predictable. Speak softly, never turn back



Offer

reassurance and support allow ventilation

Non pharmacological intervention

Preferred Verbal intervention Voluntary medication Show of force Emergency medication Offer food beverage or other assistance Alternate Restraints – physical , locked seclusion 

Intervention for imminent violence

  Classical

Neuroleptics:



◦ Haloperidol(5-10mgs) ◦ ◦

 Novel 

◦ Risperidone ◦ Olanzapine ◦ Quetiapine  

 Benzodiazapines 

◦ Lorazepam(1-4 mgs)

Oral options

 Haloperidol

(5-10 mgs)



Zuclopenthixol

Accuphase

◦ Reduces injection frequency but it has a delayed onset of action 3-4 hours, effects last 2-3 days, including sedation, EPS



Lorazepam

2-4 mgs



Olanzapine

I.M. options

Flow chart for rapid tranquillisation of acutely disturbed patient

Atakan, Z. et al. BMJ 1997;314:1740

Disturbance

◦ ◦ ◦ ◦

in

consciousness alertness, awareness, sustain or shift attention.





 

Cognition - poor memory due to inattention and registration, thought disorganized, perceptual distortions, mood liability, fail recognize people Fluctuations, temporal course worse night , onset sudden

Delirium