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Justified use of Emergency intervention:

  What is a ‘Psychiatric emergency’?

  Direct threat/assault
  Refusal to cooperate
EMERGENCIES IN PSYCHIATRY   Russo-Japanese war (1904-05)
  Intense staring
Brief crisis-intervention
  Motor restlessness
  Purposeless movement
  Affective lability
 Gerson & Bassuk, 1980 –
APA taskforce on Psychiatric emergency   Loud speech
services (PES)   Irritability
  Intimidating behavior
“TRIAGE” Model – Evaluation, Containment &   Aggression to property
Referral   Demeaning/hostile verbal behavior

The First Priority, ALWAYS – SAFETY THE VERDICT

-  The Room
-  Other personnel
-  Weapons screen h/o h/o h/o h/o
h/o
-  Exit violent abnormal unrespons suicidality old case of
behavior behavior iveness psychiatry
(confusion,
DO NO HARM intoxication
etc)
Goal of intervention – Short-term: Safety
- Long-term: Collaboration with
patient

Visual examination of patient – “Eyeballing”

Suspect medical etiology
Investigations:
Can the patient be interviewed? HISTORY:
History from family / accompanying persons about •  Age: >40, < 12 -  What we do… LFT, RFT, S.electrolytes, RBS
immediate •  Acute onset -  CBC
concern •  Fluctuating course -  ECG
•  H/o medical or neurological -  Toxicology and substance screen
Immediate intervention illness -  BAC
- Verbal •  No previous psychiatric -  Neuroimaging (…LP)
- Offering assistance / voluntary medication history -  Ammonia levels
- Medication / restraint / seclusion •  Medication
•  Substance EXAMINATION:
RULE OUT MEDICAL ETIOLOGY •  Clouded consciousness
- vital signs •  Disorientation
- medical history / substance •  Abnormal vital signs
- visual examination; detailed/focused GPE •  Visual/olfactory hallucinations
- brief cognitive assessment •  Cognitive deficits
- laboratory work-up

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VIOLENT / AGITATED BEHAVIOR

Medication selection: Special considerations in medication
selection:
-  Available i/m or liquid form - Pregnancy MEDICAL Neurological
-  Speed of onset - H/o EPS Seizures
-  H/o response to medication - H/o substance use Metabolic
Hypoxia
-  Production of clinically useful - COPD
Endocrinological
sedation - Frail elderly
-  Limited liability for side-effects - Cardiac problems SUBSTANCE INDUCED Intoxication (alcohol,
inhalant)
-  Patient preference - MR / developmental delay
Withdrawal (alcohol,
Benzodiazepines > Conventional antipsychotics > sedatives)
Atypicals Delirium tremens
PSYCHIATRIC Psychosis
(10 + 4) or (5 + 2) Neurosis
- greater efficacy Personality disorder
- faster onset Social maladjustment
- lesser side-effects Interpersonal stress

VIOLENT
Cardiovascular Hypertension BEHAVIOR SUBSTANCE WITHDRAWAL SUBSTANCE INTOXICATION
Predominant anxiety – ALCOHOL Tachycardia, Hypertension
MVP
Impending MI Tremors, Sweating ALCOHOL Mood
Pulmonary embolism Nausea, Vomiting Judgment
SABE Agitation Coordination
Paroxysmal atrial Agitation
tachycardia Seizures, Delirium Transient hallucinations
Cardiac arrhythmias BENZODIAZEPINES Vital signs raised Autonomic instability
Internal hemorrhage Hyperthermia
Respiratory Hyperventilation syndrome Nausea, vomiting, loss of Medical conditions
appetite Opioids Drowsiness
Slurred speech
Seizures, Delirium Respiration; Arrhythmias
Endocrinologic Hyperthyroidism OPIATES Nausea, vomiting, diarrhoea Pupils
Pheochromocytoma Mydriasis ‘Blue’
Muscle cramps Needle marks
Metabolic Hypocalcemia Lacrimation, rhinorrhoea
Hypokalemia ‘Flu-like’ weakness
Piloerection, yawning

DELIRIUM TREMENS
Management
CANNABIS Euphoria
Anxiety
A toxic confusional state associated in alcohol
‘Slowing of time’ withdrawal state Rule out medical causes
Impaired judgment,
coordination Triad: clouding of consciousness and confusion Setting
Increased appetite + multimodality hallucinations
Conjunctival injection + marked tremor Minimal use of medication; BZDs, Antipsychotics low
Tachycardia dose
+/- delusions, agitation, insomnia, autonomic
arousal Vitamin supplementation

Peak: 72-96 hours Hydration, nutrition

R/F: Severity and duration of dependence

Severe withdrawal symptoms at presentation
Past h/o DT
Elderly, medical comorbidity

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SUICIDAL PATIENT Psychiatric illnesses

Brought with recent attempt / intent Current presentation of suicidality

Current signs and symptoms of psychiatric disorders with particular attention to

General principles of care hold good Suicidal or self-harming thoughts, plans, behaviors, and intent
mood disorders (primarily major depressive disorder or mixed episodes),

schizophrenia, substance use disorders, anxiety disorders, and personality

Specific methods considered for suicide, including their lethality and the patient’s disorders (primarily borderline and antisocial personality disorders)

Medical condition (ALWAYS SUSPECT) expectation about lethality, as well as whether firearms are accessible

Previous psychiatric diagnoses and treatments, including illness onset and course

Evaluation… leading to a Multi-axial diagnosis for Evidence of hopelessness, impulsiveness, anhedonia, panic attacks, or anxiety
and psychiatric hospitalizations, as well as treatment for substance use disorders

suicidal patient
Reasons for living and plans for the future

1) Suicidality
2) Psychiatric diagnosis Alcohol or other substance use associated with the current presentation

3) Previous attempts
4) Psychosocial situation Thoughts, plans, or intentions of violence toward others

Risk for suicide

Treatment setting; No suicide contract

GOAL: DECREASE RISK

Psychosocial situation
UNRESPONSIVE PATIENT
History
First things first – A B C ?, Immobilisation?, i.v.
Acute psychosocial crises and chronic psychosocial stressors, which may include

Previous suicide attempts, aborted suicide attempts, or other self-harming behaviors
actual or perceived interpersonal losses, financial difficulties or changes in

fluids?
socioeconomic status, family discord, domestic violence, and past or current

Previous or current medical diagnoses and treatments, including surgeries or sexual or physical abuse or neglect
Cause could be anything from head to toe !
hospitalizations
Neurologic Psychiatric
Employment status, living situation (including whether or not there are infants or
Comprehensive
1- Locked-inHistory
syndrome+ GPE

Family history of suicide or suicide attempts or a family history of mental illness, children in the home), and presence or absence of external supports
1- Catatonia
  Exact circumstances
2- Isolated of onset
frontal lobe
including substance abuse

  Injury 2- Severe depression
Family constellation and quality of family relationships
damage
  Known medical
3- Akinetic illness
mutism
3- Conversion
Cultural or religious beliefs about death or suicide
  Fever
4- Isolated
global reaction
  Oral intake
aphasia 4- Malingering
Individual strengths and vulnerabilities

Coping skills

  Substance use
Personality traits
  Seizures
Past responses to stress
  Poisoning
Capacity for reality testing

Ability to tolerate psychological pain and satisfy psychological needs

CATATONIA OLD CASE OF PSYCHIATRY

The constellation: Management
SYMPTOM DRUG-RELATED
  Movement abnormalities -General principles for ‘unresponsive’ patients RELAPSE
- Marked psychomotor disturbance -  Drug default -  Toxicity
- Extreme negativism -Benzodiazepines -  Breakthrough -  Side-effects
- Mutism Lithium toxicity
- Peculiar voluntary movement -ECT
Akathisia
- Echolalia, echopraxia Dystonias
Use of antipsychotics… controversial!
Neuroleptic malignant
  In the background of syndrome
-Schizophrenia Serotonin syndrome
-Mood disorder Drug overdose
-General medical conditions
  Always, ask for reason for current
presentation.

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NEUROLEPTIC
The MALIGNANT
constellation: SYNDROME
In who ??
Young Male Again, there is always a differential to be ruled out! Management
  Muscle rigidity &
Elevated temperature Concurrent medical – Primary CNS disorders - Early identification of risk factors and features
  Rapid or gradual onset - Dehydration Systemic disorders
- Psychomotor agitation Psychiatric medication related - Stop antipsychotics
  Diaphoresis, - Encephalitis / TBI
tachycardia, elevated or - Low serum iron To ask for – - IV support, vitals monitoring
labile BP •  Fever, headache, vomiting
  Dysphagia or Psychiatric diagnosis –
•  Seizures - Parenteral BZDs are useful
incontinence - Mood disorder
  Tremor - Preexisting catatonia •  Trauma
  Varying consciousness - H/o NMS •  Heat exposure
  Mutism •  Endocrine changes Persisting or worsening clinical picture requires referral to
Medication – •  Exactly what medication medical ICU.
  Lab evidence: CPK, LFT, -Acute parenteral antipsychotics •  Drug abuse
Leukocytosis -High potency FGAs Re-challenge with antipsychotics (5 days/complete
-Concurrent Li resolution)
-High dose Start low, go slow with close monitoring
-Increase dose; intermittent
noncompliance

ACUTE DYSTONIA ACUTE AKATHISIA

Management
Within minutes-days Within weeks
Increase antipsychotic; decrease THP! Urgent Medication changes
SSRIs / antipsychotic
o  Deviation of eyes Diphenhydramine 50mg IM stat
o  Impaired breathing
o  Protrusion of tongue, dysfunction o  ‘Inner sense of restlessness’ + Objective restlessness
o  Impaired talking; thickened or slurred speech - Decreased prevalence with HPL + LZM Important to distinguish from psychiatric symptoms /
o  Impaired swallowing medical
- Anticholinergic medication
o  Trismus causes
o  Torticollis
o  Posturing of limbs and trunk
R/F: Older age female with mood disorder/
R/F – Young black men with f/h/o movement preponderance of negative symptoms/cognitive
disorder started on high potency neuroleptics dysfunction and anemia rapidly started on high dose of
high potency antipsychotics

LITHIUM TOXICITY
Management Features – Risk factors – No plasma level correlate

BZDs / Propranolol Gastrointestinal: Excessive intake   Usually level above 1.0-1.5 meq/L taken as
- Anorexia Reduced excretion ‘toxic’
Adjusting antipsychotic dosages - Nausea Low-Na diet Correction involves –
- Diarrhoea Dehydration -  Discontinuation of lithium
-  Correction of dehydration
Neurological: Elderly -  Electrolyte balance
-Dysarthria Organically impaired
-Ataxia
-Coarse tremor Drug interactions   Above 2 meq/L – osmotic or forced alkaline
diuresis
Ominous:
-Altered consciousness   Above 3 meq/L – Dialysis
-Myoclonus,
Fasciculations
-Seizures
-Coma

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ANTIDEPRESSANT DISCONTINUATION SYMPTOMS

Management
On stopping / skipping
Re-introduction and gradual taper
Mostly with: Amitryptiline, Imipramine, Paroxetine,
Other important issues:
Venlafaxine Use of anticholinergic agents in TCA withrawal
Use of Fluoxetine in venlafaxine and clomipramine Confidentiality
Symptoms: withdrawal
o  Affective Documentation
o  GI
o  Neuromotor Privileged communication
o  Vasomotor; Flu-like symptoms
o  Neurosensory Informed consent
o  Other neurological

R/F: Children or adoloscents, had anxiety after

start of therapy, discontinued drug after >8weeks, 39
are also on other medication, have h/o