DR AHMAD ASHRAF ILMAN BIN ZULBAHRI

PSYCHIATRIC EMERGENCIES
PRESENTATION OUTLINE
▸ Introduction

▸ General principles

▸ Severe behavioural disturbance

▸ Management of delirium

▸ Deescalation, PRN medications, rapid tranquillisation

▸ Delirium tremens

▸ Neuroleptic malignant syndrome

▸ Serotonin syndrome
PSYCHIATRIC EMERGENCIES

INTRODUCTION
▸ Acute disturbance of behaviour, thought or mood of a
patient which if untreated may lead to harm, either to the
individual or to others in the environment.

▸ Differs from other medical emergencies in that the danger

of harm to the society is also taken into account.

▸ Major and minor emergencies

▸ Major: danger to life

▸ Minor: severe incapacitation

PSYCHIATRIC EMERGENCIES

PSYCHIATRIC EMERGENCIES
▸ Suicidal patient ❌ (other CME)

▸ Violent/aggressive patient ❌ (other CME)

▸ Severe behavioural disturbance

▸ Substance intoxication & withdrawal (e.g. delirium tremens)

▸ Effects of prescribed psychoactive drugs, e.g.

▸ Neuroleptic malignant syndrome

▸ Serotonin syndrome
PSYCHIATRIC EMERGENCIES

GENERAL PRINCIPLES
▸ Primum non nocere ▸ Consult
▸ own & staff safety ▸ Document
▸ always suspect/exclude ▸ decisions and reasons
organicity ▸ names of colleagues
▸ harm > confidentiality involved/consulted
▸ Assess
▸ full assessment
▸ best quality information
▸ immediate action if
situation requires
SEVERE BEHAVIOURAL DISTURBANCE

SEVERE BEHAVIOURAL DISTURBANCE

▸ Qualitative acute change in a person’s normal behaviour

▸ Manifests primarily as antisocial behaviour

▸ shouting, screaming, ↑ activity (disruptive/intrusive),

aggressive outbursts, threatening violence (self &
others)

▸ Extreme circumstances (e.g. person threatening to jump

from height, involvement of offensive weapon, hostage
situation etc.) — let police handle
SEVERE BEHAVIOURAL DISTURBANCE

COMMON CAUSES
▸ Acute confusional states/delirium

▸ Drug/alcohol intoxication

▸ Acute symptoms of psychiatric disorder

▸ anxiety/panic, mania, psychosis

▸ ‘Challenging behaviour’ in brain-injured/ID patients

▸ Behaviour unrelated to primary psychiatric disorder — e.g.

personality disorder, abnormal personality traits, situational
stressors
SEVERE BEHAVIOURAL DISTURBANCE

GENERAL APPROACH
▸ Get information. Try to establish context of the behaviour

▸ Follow general principles

▸ do no harm, assess, consult, document

▸ Look for evidence of psychiatric disorder

▸ Look for evidence of physical disorder

▸ Try to establish triggers

▸ environmental/interpersonal/substance
SEVERE BEHAVIOURAL DISTURBANCE

MANAGEMENT
▸ If physical cause suspected,
▸ follow management of delirium
▸ consider use of PRN sedative medications
▸ If psychiatric cause suspected,
▸ consider pharmacological management of acute behavioural
disturbance, including rapid tranquillisation
▸ consider compulsory detention
▸ review current management plan
▸ If no physical/psychiatric cause suspected, and behaviour is
dangerous/seriously irresponsible, call guards/police
SEVERE BEHAVIOURAL DISTURBANCE

MANAGEMENT OF DELIRIUM
1. Identify & treat precipitating cause & exacerbation factors
▸ primary cause/multifactorial
▸ optimise patient’s condition: hydration, nutrition, pain
2. Provide environmental & supportive measures
▸ caretaker psychoeducation
▸ environment that is safe & optimises stimulation
▸ reality orientation techniques (same staff, clocks)
SEVERE BEHAVIOURAL DISTURBANCE

MANAGEMENT OF DELIRIUM
3. Avoid sedation unless severely agitated/to minimise risk
▸ single medication, start low go slow
▸ T. haloperidol 0.5-1mg (max 6mg/day)
▸ T . lorazepam - 1mg (max 4mg/day)
▸ T. risperidone 1-4mg (max 6mg/day)
▸ prefer antipsychotics, BDZ may worsen delirium
▸ in alcohol withdrawal, BDZs are first line
▸ regular review, aim to stop as soon as possible
4. Regular clinical review & follow up
‣ MMSE to monitor cognitive improvement in follow up
SEVERE BEHAVIOURAL DISTURBANCE

GENERAL MANAGEMENT OF AGGRESSIVE PATIENT

SEVERE BEHAVIOURAL DISTURBANCE

DE-ESCALATION PRINCIPLES
RAPID TRANQUILLISATION

RAPID TRANQUILLISATION
▸ Use of injectable medications to calm & lightly sedate

▸ What it’s not:

▸ PRN medications

▸ routine prescription

▸ deep sedation (in A&E with resus equipment &

personnel, using IV BDZ, anaesthetics)
RAPID TRANQUILLISATION

BEST PRACTICES
▸ Use deescalation/calming techniques first
▸ Use PRN medications first
▸ If need to use rapid tranquillisation, document
▸ rationale
▸ target symptoms
▸ timescales
▸ triggers
▸ total daily doses
▸ response & side effects
▸ use of other measures e.g. restraint
RAPID TRANQUILLISATION

PRN ORAL MEDICATIONS

Drug Usual dose Max/24H Onset Peak

Chlorpromazine 25/50mg 4H 1g 30-60 mins 1-4 hrs

Diazepam 2/5mg 4H 30mg 15 mins 1 hr

Haloperidol 1.5-5mg 4H 30mg 1-2 hrs 2-6 hrs

Lorazepam 0.5/1mg 4H 4mg 15-30 mins 2 hrs

Olanzapine 5mg 6H 20mg ~2 hrs 5-8 hrs

Promethazine 25/50mg 6H 100mg 15-30 mins 1.5-3 hrs

Quetiapine 25/50mg 4H 750mg 30-60 mins 1.5-1.8 hrs

Risperidone 0.5mg 4H 16mg 30-60 mins 2 hrs

RAPID TRANQUILLISATION

PRIOR TO TRANQUILLISATION
▸ ensure safety

▸ look for physical causes

▸ review medications administered over last 24 hrs

▸ ensure oral meds already offered

▸ activate local protocols for tranquillisation

RAPID TRANQUILLISATION

TRANQUILLISATION OPTIONS
▸ non-psychotic
▸ IM lorazepam 1-2mg/IM promethazine 50mg
▸ assess after 30 mins
▸ psychotic
▸ IM lorazepam 1-2mg/IM promethazine 50mg
▸ add IM haloperidol 5mg, assess after 1hr
▸ or IM olanzapine, IM aripiprazole
▸ repeat up to max dose, consult senior
▸ alternatives
▸ IM clonazepam
▸ IM CPZ if tolerant to BDZ
▸ Clopixol Acuphase
▸ *Immediate tranquillisation: IV valium 10mg (ensure flumazenil
available)
RAPID TRANQUILLISATION

INJECTABLES FOR RAPID TRANQUILLISATION

Drug Usual dose Max/24H Onset Peak

Lorazepam 1/2mg 30mins 4mg 15-30 mins 12-15 hrs

Haloperidol 5mg hrly 18mg 15-30 mins 21 hrs

Olanzapine 5/10mg 2hrly 20mg 15-30 mins 30-50 hrs

3 doses @
Aripiprazole 9.75mg 2hrly 30 mins 75-146 hrs
30mg

Promethazine 50mg 30mins 100mg 1 hr 7-15 hrs

RAPID TRANQUILLISATION

MONITORING & SIDE EFFECTS

▸ vital signs monitoring
▸ 15mins x 1hr, hourly x 4 hrs, then 4 hourly
▸ side effects
▸ EPS - IM kemadrin 5-10mg
▸ NMS - immediate medical transfer
▸ hypotension - lie flat, raise legs
▸ respiratory depression
▸ O2, raise legs, mechanical ventilation
▸ IM flumazenil 200mcg/15s
▸ repeat 100mcg/10s every 60s, max 1mg/24hrs
▸ consider medical transfer
DELIRIUM TREMENS

DELIRIUM TREMENS
▸ Delirium secondary to alcohol withdrawal
▸ Requires inpatient medical care, mortality 5-10%
▸ Onset 1-7 days since last consumption, peak at 48 hrs
▸ Risk factors: severe dependence, co-morbid infection, preexisting
hepatic impairment
▸ Features of alcohol withdrawal (tremor, sweating, insomnia,
tachycardia, N&V, psychomotor agitation, generalised anxiety), plus:
▸ Clouding of consciousness, disorientation, amnesia, marked
psychomotor agitation, hallucinations (Lilliputian), marked fluctuations
of severity
▸ Severe cases: heavy sweating, fear, paranoid delusions, agitation,
suggestibility, sudden cardiovascular collapse
DELIRIUM TREMENS

MANAGEMENT
▸ General measures
▸ correct dehydration from fever & sweating
▸ treat withdrawal symptoms e.g. nausea/vomiting
▸ focal neurological symptoms should prompt further treatment
▸ warm, supportive psychotherapt
▸ Pharmacological treatment
▸ BDZ i.e. oral diazepam up to 10mg QID
▸ oral thiamine 100mg TDS + MVT
▸ consider haloperidol only if +psychotic symptoms & BDZ fail,
as antipsychotics reduce seizure threshold
NEUROLEPTIC MALIGNANT SYNDROME

NEUROLEPTIC MALIGNANT SYNDROME

▸ rare, life-threatening,
idiosyncratic reaction
to antipsychotics

▸ FALTERED - fever,
autonomic instability,
leucocytosis, tremors,
▸ Morbidity: rhabdomyolysis,
elevated CPK, rigidity,
aspiration pneumonia, renal
encephalopathy,
failure, seizures, arrhythmias, DIC,
diaphoresis
respiratory failure, worsening of
primary psychiatric disorder
NEUROLEPTIC MALIGNANT SYNDROME

MANAGEMENT
▸ Investigations
▸ FBC, C&S, RP/LFT/ē, CE (CK), ABG, Coag
▸ Urine myoglobin, urine toxicology, ECG
▸ CXR (if aspiration suspected), consider CT Brain, LP
▸ Management
▸ prompt diagnosis, discontinue suspected agents
▸ consider transfer to appropriate setting e.g. ICU
▸ supportive measures (O2, fluids, cooling measures, urinary alkalinisation -
to reduce risk of rhabdomyolysis)
▸ BDZ for acute behaviour disturbance (injectables and restraint may
complicate CK reading)
▸ Limited evidence: dantrolene, bromocriptine, amantidine, nifedipine, ECT
SEROTONIN SYNDROME

SEROTONIN SYNDROME
▸ Rare, potentially fatal syndrome following initiation/
increase in dose of serotonergic agent (SSRI mainly,
amphetamines, MAOIs, TCAs, lithium)

▸ SHIVERS - shivering, hyperreflexia/myoclonus/ataxia,

increased temperature, vitals (autonomic) instability,
encephalopathy (altered mental status), restlessness,
sweating

▸ Ix: FBC, RP/LFT/ē, BG, RBS, CE, urine toxicology, ECG

SEROTONIN SYNDROME

MANAGEMENT
▸ Prevention: careful prescribing & education

▸ If severe, transfer to ED

▸ IV access, hydration

▸ Rhabdomyolysis: hydration, urine alkalinisation, cooling

▸ BDZ for agitation/seizures/muscular rigidity

▸ Serotonergic receptor antagonists: cyproheptadine, CPZ

(reduces seizure threshold), mirtazapine, methysergide,
propranolol
SEROTONIN SYNDROME

SS VS NMS
autonomic dysfunction, altered mental status, rigidity,
Similarities
hyperthermia

Differences NMS SS

antipsychotics, serotonergic agents, OD/

Associated Rx
idiosyncratic, normal dose drug combination

Onset slow (days to weeks) rapid

Progression slow (24-72 hrs) rapid

Muscle rigidity severe (‘lead pipe’) less severe

Activity bradykinesia hyperkinesia/clonus

 THANK YOU.
Reference:
Semple & Smyth (2019). Oxford Handbook of Psychiatry (4th ed). Oxford, England: Oxford University Press
Sudarsanan et al. (2004). Psychiatric Emergencies. MJAFI , 60:59-62
Management of Aggressive Patients in MOH Facilities