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. be able to describe acute management of common psychiatric emergencies.

 To

Objectives

     History

 Collateral

history
What

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

General assessment

  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 - Laboratory – screens- Imaging

Investigation

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  S ­ Single

 R ­ Rational thinking absent  O ­ Organized attempt

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

Risk factors for suicide

Not

just psychiatric disorders (although commonest cause). “non-psychiatric” causes

Numerous

Needs

full medical/psychiatric work up

High

dose benzodiazepines/ECT

Catatonia/Mute

   Agitation

is excessive motor or verbal activity. examples include:

 Common

◦ ◦ ◦ ◦ ◦

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). brain syndromes (7-28%)

 Organic

Violent Patient


Ensure

safety of patient and staff.

To

determine if ideation or behavior stems from specific psychiatric illness. third parties of a serious threat of harm is present.

Warn

To

draw an effective and appropriate treatment plan.

Violent Patient

Remove

potential weapons e.g. keys, chairs.

Get

other patients to safe place. patient in quiet setting, reduce stimulation.

Put

Attitude

- nonjudgmental, calm, helpful, slow, predictable. Speak softly, never turn back reassurance and support allow ventilation

Offer

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:

 Novel

◦ Haloperidol(5-10mgs) ◦ ◦ ◦ Risperidone ◦ Olanzapine ◦ Quetiapine

 

 Benzodiazapines

◦ Lorazepam(1-4 mgs)

Oral options

 Haloperidol

(5-10 mgs) Accuphase

Zuclopenthixol

◦ 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

◦ ◦ ◦ ◦

consciousness alertness, awareness, sustain or shift attention.

in

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

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