Psycyhiatric Emergency: Dr. H. Abdulllah Shahab, Sp.kj Bag. Ikj Fk Unsri - Departemen Jiwa Rsmh

PSYCYHIATRIC EMERGENCY

The Star of Life, representing emergency medical services

Dr. H. Abdulllah Shahab, Sp.KJ Bag. IKJ FK Unsri - Departemen Jiwa RSMH

INTRODUCTION  DEFINITION Emergency Psychiatry / Psychiatric Emergency is the clinical application of psychiatry in emergency settings. Psychiatric Emergency Services (PES) is a 24-hours a day service provided for psychiatric emergencies for both voluntary and involuntary patients

 CONDITIONS REQUIRING INTERVENTIONS 1. 2. 3.

4. 5. 6. 7. 8.

Suicide Substance Abuse Anxiety/Panic Disaster Abuse, physical/sexual Psychosis Violence or other rapid changes in behaviour

PSYCHIATRIC EMERGENCY SERVICES (PES) 

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The facilities, sometimes housed in a psychiatric hospital, psychiatric ward, or emergency room, provide immediate treatment to both voluntary and involuntary patients The treatment team features a multidisciplinary approach, with professionals from psychiatry, social work, psychiatric nursing, chemical dependency and community mental health

Clinical Staff consists of:  

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Psychiatrists Emergency Physicians Mental Health associates: Medicine, Nursing, Psychologist, Social Work Registration/Admitting clerks

Services include:   

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Diagnostic psychiatric evaluations for the presence of a mental illness. Assessment and reassessment. If necessary, admission to inpatient facility. Crisis intervention related to a psychiatric illness. Linkage and referral to ongoing mental health services. Referrals may be given for medical, dental, legal, social, or substance abuse services. Ambulatory detoxification services are provided by referral only in conjunction with enrollment in an intensive treatment program.

SERVICE PROCEDURE

PATIENT

TRIAGE

MINOR AND SERIOUS SYMPTOMS

ASSESSMENT

LIFE-THREATENING SYMPTOMS

CRISIS STABILIZATION

DISPOSITIONAL OPTION

TREATMENT PLANNING

1. Suicide attempts and suicidal thoughts 

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As of 2000, the World Health Organization estimated one million suicides each year in the world. predict acts of violence patients may commit against themselves (or others), even though the complex factors leading to a suicide stem from so many sources, including psychosocial, biological, interpersonal, anthropological and religious use any resources available to them to determine risk factors, make an overall assessment, and decide on any necessary treatment.

2. Substance abuse, dependence, intoxication 

Psychoactive drugs - intoxication,

Alcohol: idioyncratic intoxication could occur in some individuals even after the consumption of relatively small amounts of alcohol. Episodes of this impairment usually consist of confusion, disorientation, delusions and visual hallucinations, increased aggressiveness, rage, agitation and violence. Acting as a depressant of the central nervous system, the early effects of alcohol are usually desired for and characterized by increased talkativeness, giddiness, and a loosening of social inhibitions. Besides considerations of impaired concentration, verbal and motor performance, insight, judgment and short term memory loss which could result in behavioral change causing injury or death, levels of alcohol below 60 milligrams per deciliter of blood are usually considered non-lethal. Chronic alcoholics may also suffer from alcoholic hallucinosis, wherein the cessation of prolonged drinking may trigger auditory hallucinations. Such episodes can last for a few hours or an entire week.

Alcohol………. 

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However, individuals at 200 milligrams per deciliter of blood are considered grossly intoxicated and concentration levels at 400 milligrams per deciliter of blood are lethal, causing complete anesthesia of the respiratory system. Patients may also be treated for substance abuse following the administration of psychoactive substances containing amphetamine, caffeine, tetrahydrocannabinol, cocaine, phencyclidines, or other inhalants, opioids, sedatives, hypnotics, anxiolytics, psychedelics, dissociatives and deliriants the clinician must determine substances used, the route of administration, dosage, and time of last use to determine the necessary short and long term treatments. An appropriate choice of treatment setting must also be determined.

3. Anxiety / Panic 

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Feelings of anxiety may present in different ways from an underlying medical illness or psychiatric disorder, a secondary functional disturbance from another psychiatric disorder, from a primary psychiatric disorder such as panic disorder or generalized anxiety disorder, or as a result of stress from such conditions as adjustment disorder or post-traumatic stress disorder. Clinicians usually attempt to first provide a "safe harbor" for the patient so that assessment processes and treatments can be adequately facilitated. The initiation of treatments for mood and anxiety disorders are important as patients suffering from anxiety disorders have a higher risk of premature death

4. Disasters 

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Natural disasters and man-made hazards can cause severe psychological stress in victims surrounding the event. Emergency management often includes psychiatric emergency services designed to help victims cope with the situation. The impact of disasters can cause people to feel shocked, overwhelmed, immobilized, panic-stricken, or confused. Hours, days, months and even years after a disaster, individuals can experience tormenting memories, vivid nightmares, develop apathy, withdrawal, memory lapses, fatigue, loss of appetite, insomnia, depression, irritability, panic attacks, or dysphoria. Dependent upon the scale of the disaster, many victims may suffer from both chronic or acute post-traumatic stress disorder. Patients suffering severely from this disorder often are admitted to psychiatric hospitals to stabilize the individual

5. Abuse, physical / sexual 

Incidents of physical abuse, sexual abuse or rape can result in dangerous outcomes to the victim of the criminal act. Victims may suffer from extreme anxiety, fear, helplessness, confusion, eating or sleeping disorders, hostility, guilt and shame. Managing the response usually encompasses coordinating psychological, medical and legal considerations.

6. Psychosis 

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Patients with psychotic symptoms are common in psychiatric emergency service settings. An individual could also be suffering from an acute onset of psychosis. Such conditions can be prepared for diagnosis by obtaining a medical or psychopathological history of a patient, performing a mental status examination, conducting psychological testing, obtaining neuroimages, and obtaining other neurophysiologic measurements

7. Violent behavior 

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Aggression can be the result of both internal and external factors that create a measurable activation in the autonomic nervous system. Violence is also associated with many conditions such as acute intoxication, acute psychosis paranoid personality disorder, antisocial personality disorder, narcissistic personality disorder, and borderline personality disorder.

TREATMENT 1) Medications

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the rapidity of effect is an important consideration.[16] Pharmacokinetics is the movement of drugs through the body with time and is at least partially reliant upon the route of administration, absorption, distribution and metabolism of the medication In cases of vomiting and nausea this method of administration is not an option. Suppositories can, in some situations, be administered instead.[10] Medication can also be administered through intramuscular injection, or through intravenous injection. Generally, though, the timing with medications is relatively fast and can occur within several minutes. As an example, physicians usually expect to see a remission of symptoms thirty minutes after haloperidol, an antipsychotic, is administered intramuscularly.

2) 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, the patient trusts the physician, the physician can encourage hope for change, the patient has motivation to change, the physician is aware of the psychopathological history of the patient, and the patient understands that their confidentiality will be respected.

 If the physician determines that deeper psychotherapy

sessions are required, he or she can transition the patient out of the emergency setting and into an appropriate clinic or center

3) Electro Compulsive Therapy (ECT) 

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Electroconvulsive therapy is a controversial form of treatment which cannot be involuntarily applied in psychiatric emergency service settings. Instances wherein a patient is depressed to such a severe degree that the patient cannot be stopped from hurting himself or herself or when a patient refuses to swallow, eat or drink medication, electroconvulsive therapy could be suggested as a therapeutic alternative. While preliminary research suggests that electroconvulsive therapy may be an effective treatment for depression, it usually requires a course of six to twelve sessions of convulsions lasting at least 20 seconds for those antidepressant effects to occur

4) Hospital admission 

The emergency care process. The staff will need to determine if the patient needs to be admitted to a psychiatric inpatient facility or if they can be safely discharged to the community after a period of observation and/or brief treatment. Initial emergency psychiatric evaluations usually involve patients who are acutely agitated, paranoid, or who are suicidal. Initial evaluations to determine admission and interventions are designed to be as therapeutic as possible

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