Psychiatric Emergency ‫هالة رعد‬.

‫د‬
‫ن فسية عملي‬

Severe Behavioral Disturbance

Represent a qualitative acute change in a person’s normal
behaviour that manifests primarily as antisocial behaviour, e.g.
shouting, screaming, (often disruptive/intrusive) activity, aggressive
outbursts, threatening violence (to others or self).

Common causes
• Acute confusional states (Delerium)
• Drug/alcohol intoxication
• Acute symptoms of psychiatric disorder (anxiety/panic, Panic
disorder, mania, schizophrenia/other psychotic disorder.
• ‘Challenging behaviour’ in brain-injured or ID patients.
• Behaviour unrelated to a primary psychiatric disorder—this may
reflect personality disorder, abnormal personality traits, or situational
stressors (e.g. frustration).

Management
Important points to look for in history:
• Look for evidence of a possible psychiatric disorder.
• Look for evidence of a possible physical disorder.
• Try to establish any possible triggers for the behaviour—
environmental/interpersonal stressors, use of drugs/alcohol, etc.
Management will depend upon the assessment made:
1. If physical cause suspected:
• Follow the management of delirium.
 • Consider use of PRN sedative medication to allow proper
examination, to facilitate transfer to medical care (if
(1)
indicated), or to allow active (urgent) medical management.
2. If psychiatric cause suspected:
• Consider pharmacological management of acute behavioural
disturbance, including rapid tranquillization (RT), if indicated.

3. If no physical or psychiatric cause suspected, and behaviour

is dangerous or seriously irresponsible, inform security or the
police to have the person removed from the premises (and
possibly charged if a criminal offence has been committed,
e.g. assault, damage to property)

Rapid Tranquillization (RT)—guidelines and use

of PRNs

RT (or ‘urgent sedation’) is the use of injectable medication

to calm and lightly sedate a patient who is in a highly
distressed, agitated, aggressive, or behaviourally disturbed state
in order to: (1) reduce the risk to self and/or others;
and (2) allow psychiatric evaluation to take place (which
will necessitate spoken communication).
It is not ‘PRN’ medication and should not be routinely
prescribed (or prescribed as ‘PO/IM’). RT is also not the
induction of ‘deep sedation’ with reduced consciousness and
motor and sensory activity, and ultimately loss of airway
control and protective reflexes (requiring supportive measures),
although this may be the result of repeated RT—hence the
need for close physical monitoring.
 (2)

Typical PRN oral medications for acute

behavioural disturbance
1. Diazepam: 2-5 mg( 4 hourly), maximum 30 mg
2. Chlorpromazine25/50mg (4hourly) maximum 1gm
3. Lorazepam: 0.5/1mg (4-hourly) maximum 4mg
4. Haloperidol: 1.5–5mg (4-hourly)maximum 30mg

Potential risks of pharmacological management

• Over-sedation causing LOC and compromise of airway.
• Cardiovascular or respiratory collapse (raised risk where there
is stress or extreme emotion or extreme physical exertion).
• Interaction with prescribed or illicit medication.

Rapid Tranquillization Options

❖ Non-psychotic context
• IM lorazepam 1–2mg (or IM promethazine 50mg in those with
compromised respiratory function or known to be sensitive/tolerant
to BDZs), and wait 30mins to assess response.

❖ Psychotic context
• IM lorazepam 1–2mg (or IM promethazine 50mg), and wait
30mins to assess response.
• If insufficient, add IM haloperidol 5mg (wait 1hr to assess
response) or IM olanzapine 5–10mg (do not give IM
lorazepam within 1hr of IM olanzapine) .
 (3)

Note: haloperidol is usually reserved for those with previous

antipsychotic use and a normal ECG.
SGAs are less likely to cause significant side effects in the
antipsychotic-naive or those with evidence of cardiovascular
disease, prolonged QTc, no ECG, on drugs that can affect
QTc or alcohol or illicit drug intoxication.
If other measures have been ineffective, or if patient likely to
be tolerant to BDZs, consider IM chlorpromazine 25–100mg
every 30–60mins. (Note: danger of postural hypotension, and
even fatality, if given inadvertently by IV injection—
monitoring essential and nurse lying down.)

Physical health monitoring during and after

rapid tranquillization

•Temperature, pulse, BP, O2 saturation, and

respiratory rate (RR)should be recorded every 15mins for the
first hour, then hourly for4hrs, then, depending on clinical need,
every 4hrs for the next12hrs. Local paperwork may be available.
.•If the patient is asleep, they should be woken, unless there is
agood reason not to. At the very minimum, respiratory and pulse
rates should be recorded and the reason for not doing more noted
clearly.
 (4)

Common and serious side effects

1.EPS (especially acute dystonia following haloperidol, utilize

IM procyclidine 5–10mg
2.NMS: will need immediate clinical transfer.

3. Hypotension: lie the patient flat, and raise legs; monitor

closely.
4. Respiratory depression: give O2, raise legs, if
necessary ventilate mechanically. If RR drops below 10
breaths/min after BDZ administration, call for advanced
emergency care: IV flumazenil 200mcg over 15s; if
consciousness is not resumed within 60s, give 100mcg over
10s; repeat at 60s intervals; maximum dose 1mg/24hrs;
continue close monitoring after RR returns to normal.

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