PSYCHIATRIC

EMERGENCIES

Dr. Rabie Hawari

Consultant Psychiatrist
Clinical Assistant Professor
SUICIDE

A willful self-inflicted life-

threatening act which has
.resulted in DEATH
 ATTEMPTED SUICIDE

OR DELIBERATE SELF-HARM
OR PARASUICIDE

An act of self-damage carried out *

. with destructive intent
* An attempt without the will to
finish one’s life.
 SUICIDE RISK FACTORS
• Previous Hx. Of Affective Disorder = Depression.
• Hx. Of Alcoholism & Drug Abuse.
• Sever physical illness in the elderly = Ca.
• Recent bereavement, separation, loss.
• Family Hx. Of Affective Illness.
• Previous Suicidal Attempts.
• Personality problems i.e. Cyclothymic, Antisocial.
• Poor social support, living alone, unemployed,
single.
• Other symptoms: Agitation, Insomnia, Guilt,
Male, Older age, Divorced, Suicidal threats.
METHODS USED
examples;
.Self-poisoning:- coal gas poisoning
,Drugs- tranquilizer
,Salicylates
.Antidepressant
.Violent means:- hanging, firearm, cutting, etc
MANAGEMENT
• Active treatment of the physical condition.
• Detect high risk group.
• Close observation 1=1.
• Treatment of any Psy. Illness.
• Social & Psychological support.
• Admission to Psych. Unite if the immediate
crisis passed & the Pt. suffers from Psych.
Illness & of high risk group.
• If the situation is not one of OD. Pt. may
need sedation e.g. Nitrazepam 10-15mg.
CPZ. 100-200mg.
 DELIBERATE SELF-
HARM
An attempt without the will to finish
.one’s life
Causes:- personality Diso. e.g. Psychopath or
Hysterics
.alcoholism -
.reactive ( neurotic ) depression -
.situational crisis -
-:Correlating Factors

- not well planned act.

female, young, unemployed, -
.single
previous attempts, -
.psychosocial stresses
broken home background -
-:Management of DSH

assessment of physical -
seriousness
.admission -
assessment for Suicide Risk -
.Factor
treatment of any Psychiatric -
.Illness
.psychotherapy -
SIDE-EFFECT OF
PSYCHOTROPIC DRUGS
A. Neuroleptic Malignant Synd.
-: (NMS)
Is an acute or subacute Hyperthermic
reaction to neuroleptic therapy with a
.mortality of 20%
Features:- Hi. Fever … Extrapyramidal
rigidity … Altered consciousness …
Raised Creatine Phosphokinase (cpk)=
.15000iu/l
 -:Management of NMS
.Stop all neuroleptic drugs -
.Vigorous cooling is needed
Oxygen, i.v. hydration, prevention of renal
.failure, bicarbonate for acidosis
.Dantrolene sodium 200mg (slow),1.25-10/kg
i.v.(fast) for 12-48hr. after control of fever. or
Bromocriptine p.o. or i.v.(^ 60 mg/day)
.rigidity
;Cont. S/E. of Psych. Drugs

B. Acute Dystonia:-
Involuntary contraction
of skeletal muscles in head & neck
 Oculogyric Crisis
-:Management
I.M. Procyclidine (kemedrine) -
.5-15mg
.Diazepam 10mg i.v -
;Cont. S/E. of Psych. Drugs

C. Akathisia:- Minor restlessness &

tension. pt. unable to keep from
fidgeting, subjective feel of
.restlessness
Management:- Anti-parkinsonian
.drug
S/E. of Psych. Druges

-:D. Pseudoparkinsonism
-:This mimic idiopathic Parkinsonism
,stiffening of the limbs -
,lack of facial expression -
,tremor of hands & head at rest -
.sialorrhoea & seborrhoea -
-:Management of Ps-Parkinsonism

Stop the drug temporarily or sharply

.reduce the dose
-:Use Anti-Parkinsonian Drugs
.Benzhexol (Artane) 2- 4mg.t.i.d =
.Procyclidine ( Kemedrine) 5-15tid =
Orphenadrine( Disipal ) 50 -100mg =
.tid
MANAGEMENT OF VIOLENT
PATIENT
Usually the majority of
Psychiatric patients are not
Hostile, Dangerous or
aggressive, BUT occasionally
Psychiatric Illness presented in
Aggressive Behavior
 -:.Examples of Violent Pts

.Psychopathic Personality Disorder .1

Hypomania or mania >>> may be .2
angry & hostile if they are obstructed
Schizophrenia >> due to Delusional .3
beliefs or in response to auditory
.Hallucination
Catatonic type >> outbursts of over
.activity &/or aggressive behavior
.Cont. examples of violent Pts

-:Alcohol & Drugs .4

Alcohol >> reduce self-control>>
aggression
C.N.S. stimulants ( amphetamine ) >>
>>> over activity & over stimulation
.Aggression
.Heroin addicts during Withdrawal phase
 -:.Cont. Examples of Violent Pts

Acute Confusional State >> clouding .5

of consciousness >>> diminished
comprehension, anxiety, perplexity,
delusion of persecution >>>>
.Aggression

Epilepsy:- in the post-epileptic .6

.confusional state
.Cont. Examples of Violent Pts

Dementia:- cerebral damage >>>> .7

decreased control >> aggression
Catastrophic Reaction:- when facing
difficult tasks they become
restless, disturbed, angry,
aggressive, throw things
. & attack people mostly at night
MANAGEMENT OF
.VIOLENT PT
Doctors, Nurses, relatives should -
treat such pt. with understanding &
.gentleness as possible
.Adequate security -
.Raise of alarm -
.Availability of more staff -
.clear prevention policy to all -
.Remain calm, non-critical -
 .Cont. Manage. Of Violent pt
Use minimum force with adequate -
.numbers of staff
.Talk pt. down -
.Physical restrain -
-:Medication -
typical :- Major Tranquilizer *
Chlorpromazine 50-100mg im .
.Droperidol 10-20mg im or iv .
Clopixol Aquaphase 50-100mg im .
atypical:- risperidone 4mg Or *
.zyprexia 10mg im
.Cont. manage. Of violent pt

-:.Medication cont
Benzodizepine:- Diazepam 5-10mg *
iv. In epilepsy, withdrawal of
.alcohol or barbiturates
).may disinhibit violence (
DELIRIUM TREMENS
D.T. :- arises 2-4 days after sudden
withdrawal or stopping of alcohol
features:- hallucinate, delusion, confused,
inattentive, agitated, restless, insomnia,
tearful, autonomic overactivity, coma,
.death
management:- Benzodiazepine p.o or iv. to
reduce WD symptoms in large doses &
taper off in a wk. + large doses of vit. B.
.and correct fluid & electrolyte
ACUTE CONFUSIONAL
.STATE
-: Characterized by
,clouding of consciousness *
,disorientation *
,visional hallucination *
.perplexity, disturbed behavior *
-:Management
,admission -
treat underlying cause ( infection) -
,explain to pt. investigations, treatment -
in clear voice & well lit room, reduce staff
.chlorpromazine or haloperidol for control -
ACUTE ATTACKS OF
ANIETY OR PANIC
-:Features
,experiences of intense terror .1
,sweating & drying of mouth .2
& feeling of distress in chest .3
,pericardial pains
,transmitted to members of family .4
.often at w/ends or middle of the night .5
-:Management
,reassurance -
Benzodiazepine. ( diazepam 5-10mg po/iv) -
 -:OTHERS
-:STUPOR
cause Akinesia, Immobility, Muteness with
preserved consciousness. It is life
.threatening b/c of dehydration
-: causes
,functional depression, catatonia -
.hysterical, mania
,organic 20%, Brain Stem Lesions -
.lesions around 3rd.Ventrical
-:management
Abreaction ( Na. amytal or Diazepam) -
.ECT. - And treat the underlying -
 -:OTHERS
-:BRIEF REACTIVE PSYCHOSIS
,emotional turmoil, extreme liability
impaired reality testing after obvious
.psychosocial stress

,Management:- admit, antipsychotic

.resolves spontaneously
 -:OTHERS

-:HYPERVENTILATION
,anxiety, terror, clouded conscious
.giddiness, faintness, blurring vision

Management:- breathe into bag shift

alkalosis, education, antianxiety
.agent