EMERGENCIES

IN PSYCHIATRY
ANITA ARINDA, MMED PSYCH.
OUTLINE
 Definition

 Categories of emergencies

 Strategy in evaluating the patient

 Individual emergency discussion

DEFINITION
 A psychiatric emergency is any disturbance in thoughts, feelings
or actions or cognition for which immediate therapeutic
intervention is necessary to prevent harm to a patient or others
or property.

 Arise in the context of:

 Psychiatric illness (both acute & chronic)
 Medical illness
 Adverse drug reaction / intoxication
 Severe physical or emotional trauma
CATEGORIES
 Suicide
 Acute psychosis
 Aggression/violence
 Neuroleptic malignant syndrome
 Acute dystonia
 Serotonin syndrome
 Status epilepticus
 Substance intoxication/withdrawal
 Delirium
 STRATEGY IN EVALUATING
THE PATIENT
1. Self-protection
 Know as much as possible about the patients before meeting
them.
 Leave physical restraint procedures to those who are trained.
 Be alert to risks of impending violence.
 Attend to the safety of the physical surroundings (e.g., door
access, room objects).
 Have others present during the assessment.
 Have others in the vicinity
 Attend to developing an alliance with the pt
 STRATEGY IN EVALUATING
THE PATIENT
2. Prevent harm
 Prevent self-injury and suicide.
 Prevent violence toward others
 briefly assess the patient for the risk of violence and risk to
property

3. Rule out organic mental disorders

4. Rule out impending psychosis.

 STRATEGY IN EVALUATING
THE PATIENT..
 At a minimum, address the following questions before any
disposition is decided on:
 Is it safe for the patient to be in the emergency room?
 Is the problem organic or functional or a combination?
 Is the patient psychotic?
 Is the patient suicidal or homicidal?
 To what degree is the patient capable of self-care?
SUICIDE
SUICIDE
 Suicide is derived from the Latin word for ‘self-murder’

 Is a fatal act that represents the person’s wish to die

 Is self-inflicted death with explicit or implicit evidence

that the person intended to die

 Suicide is the primary psychiatry emergency

TERMS IN SUICIDAL BEHAVIOUR
 Suicidal ideation- thoughts of serving as the agent of one’s own death

 Aborted suicide attempt- potentially self-injurious behaviour with evidence

that the person intended to die but stopped the attempt before physical damage
occurred

 Suicidal attempt -a self-injurious behavior with a nonfatal outcome

accompanied by evidence that the person intended to die.

 Suicidal intent- subjective expectation & desire for a self-destructive act to

end in death

 Deliberate self-harm- willful self-inflicting of painful, destructive, or

injurious acts without intent to die
EPIDEMIOLOGY
 RISK FACTORS
Risk Factor Pattern
Age Elderly are at a greater risk of completed suicide
(greater risk)
Peak age in males 45 and in females 55

Gender Suicide attempt:3x in women

Completed suicide: 4x in men

Marital Status Widowed, divorced, or single marital status,

particularly for men. Marriage reduces risk.

Substance use Higher risk in those with substance dependence esp.

alcohol
Religion Historically, higher rates in protestants & Jews than
Catholics. Lower rates in Muslims
Occupation Higher among unemployed, high social class, drop in
social status
 RISK FACTORS CONT’D
Risk factor Pattern
Stressors Presence of recent severe stressors financial,
marital, family etc.

Social Support Lack of social support

Physical Illness Severe physical illnesses especially chronic

increases risk.
Psychiatric Diagnosis Major depression or schizophrenia, as well
as a previous suicide attempts
Previous suicidal Risk of second attempt is highest within 3
months of first attempt
behaviour
Personality Disorder High risk in borderline personality

Family History Increased risk if there is positive history of

completed or attempted risk
 MANAGEMENT OF SUICIDE
Assess the risk
 Comprehensive history regarding suicidal ideas, plans, intent
attempts, lethality and assessment of the established risk factors.
 Assess presence if any of the symptoms of psychiatric disorders.

 Medical history and substance use history .

 Family history of mental illness and suicides .

 MSE, physical examination and relevant investigations.

 Assess suicide risk- SAD PERSONS scale

MODIFIED SADPERSONS SCALE
 MANAGEMENT OF SUICIDE
CONT…
 Form treatment alliance

 Ensure patient safety

 Admit voluntarily or involuntarily

 Remove the potential agents (medicines, objects, electric
sockets, ..)

 Constant observation- CAUTION card

 Keep visitations to the minimum

 Continuously assess the risk: BSS (Beck’s Suicide Scale)/

SADPERSONS scale
MANAGEMENT OF SUICIDE CONT…
 Psychotherapeutic intervention – widely viewed as helpful
for suicidal patients, evidence is limited

 Medication if any disorder

 ECT if severely depressed

 Psycho-education to the family members.

 Monitor psychiatric status and response to treatment.

 Reassess for safety and suicide risk frequently.

ACUTE
PSYCHOSIS
DEFINITION
 ACUTE
 Sudden
 Rapid
 Calls for immediate action.

 PSYCHOSIS
 Disturbed reality testing
 Presence of:
 Delusions
 Hallucinations
 Thought Disorder
 +/- Behavioral Disturbance
 Acute Psychosis is often a Psychiatric emergency
CAUSES OF PSYCHOSIS
PRIMARY: Also called Functional Psychoses
Affective Psychosis
Mania
Psychotic Depression
Schizoaffective Disorder

Schizophrenia

Other Primary delusional disorders

CAUSES OF PSYCHOSIS…
SECONDARY: Also called symptomatic psychoses
 Traumatic
 Drug Induced psychosis
 Infections
 Organic brain lesions: Neoplastic, CVAs.
 Dementia
 Metabolic derangements
 Endocrinologic
 Post-partum
MANAGEMENT:
INVESTIGATIONS
 BIOLOGICAL /PHYSICAL INVESTIGATIONS
 CBC
 LFT: GGT, SGOT, SGPT, Alk Phos, BIL
 TFT
 Serologies: HIV, TPHA, WIDAL
 Metabolic (RBS, Serum amylase, B-12
 BUN & Electrolytes
 Drug screens: THC, amphetamines, lsd, cocaine, opiates
 Imaging: U-S, Brain CT- & MRI-SCAN

 PSYCHOLOGICAL INVESTIGATIONS
 BPRS
 As specific for each disorder – YMRS, PANSS, BDI ETC

• SOCIAL INVESTIGATIONS:
- Collateral h/o- past h/o, family h/o, police/ambulence report, friends information
PRINCIPALS OF TREATMENT
OF ACUTE PSYCHOSIS
 It is a psychiatric emergency
 Often involves more than one person

 Three components
 Immediate treatment : Control the emergency
 Short Term treatment: Control the episode
 Long Term treatment: Prevent relapse, recurrence

 Three categories
 Biological Treatment
 Psychological Treatment
 Social Treatment
TREATMENT
 Contain patient : Admit, Certify, Restrain

 Prevent Harm/damage to
 Self
 Others
 Property
 Integrity
 Finances

 Prevent development of complications

 Treat underlying cause

 Treat the episode

 Prevent Relapse
CONTAINING THE PATIENT
 Certify for involuntary admission : form 10/urgency order

 Environmental control
 Hospital grounds only: Locked gate
 Restrict to hospital: Locked units
 Restrict to room: Locked room / Seclusion rooms
 Restrict to bed: bed straps

 Restrain Patient
1. Chemical restrain
2. Physical restrain
CHEMICAL RESTRAINT
1) SEDATION : TRANQUILIZATION
Benzodiazepines
Lorazepam 2-4mg Im/Iv Q12-24 Hrly
Clonazepam 2-4mg 1m/Iv Q12-24 Hourly
Diazepam 10-20 Mg Po/Im/Iv Q8-24 Hrly

2) RAPID NEUROLEPTIZATION
Short Acting Antipsychotics Given Parenterally In Rapid Succession
 Haloperidol 5-10mg Im Q2 to 6hourly
Add Benzodiazipines As Above
Or Promethazine 50 Mg Im Q 12-24 Hourly
 Chlorpromazine 100-200mg 6-12hrly. Add Diazepam as above

3) MONITOR VITAL SIGNS:1- HOURLY

4) I-2 HOURLY NURSING OBSERVATION SHEET

PSYCHOSOCIAL
TREATMENTS
PSYCHOLOGICAL TREATMENT
 Psychotherapy (counseling) must be done
 supportive
 explanatory
 Psycho-education
 Insight-oriented: later on
 Vocational counseling

SOCIAL TREATMENT
 Supportive
 Explanatory
 Avoid expressed emotions
 No critical comments
AGGRESSION
AND VIOLENCE
AGGRESSION AND VIOLENCE
 Aggression
 Goal directed Behavior (verbal or nonverbal) for Hurt

 Violence
 Severe & Sudden Goal directed Behavior to Destruction of
property or Hurt or Kill others

 Seen in the following conditions:

 Psychotic disorders
 Bipolar disorder
 Personality Disorders
AGGRESSION AND VIOLENCE…
Risk evaluation
 Demographic Characteristics: Male ,15-24 years, Low SES
&Social Support

 Evaluation of Thought, Attempt, Plan for Violence, Weapons

Availability

 History of: Violence, Antisocial Behaviors ,Impulse Control

Disorder (Substance,….)

 History of Major Stressor: Loss, Family Discord…

AGGRESSION AND VIOLENCE:
FEATURES
 Impending Violence:

 Verbal or Physical Threatening

 Progressive Restlessness

 Weapons Carrier

 Substance or Alcohol Abuser

 Excited Catatonia

 Paranoid (Psychosis)

 Personality Disorder
MANAGEMENT
Verbal de-escalation
 Calm, slow talking
 Be firm and assertive
 Avoid argumentative or condescending language
Physical restraints
 Prevention of harm to patient or others
 Should not be applied for convenience or as a punitive
measure
Chemical restraints
 Rapid tranquilization-Antipsychotics and benzodiazepines
Environmental restraints- seclusion
NEUROLEPTIC
MALIGNANT
SYNDROME
INTRODUCTION
 A life-threatening complication due antipsychotics.

 Due to central dopamine hypoactivity.

 Anytime in treatment course

 Incidence:
 Typical antipsychotics
- Best estimate 0.02-0.03%
- Wide variance in estimates 0.01-3.0%
 Atypical antipsychotics
- It remains unclear whether atypical antipsychotics are
less likely to cause NMS compared to typical antipsychotics
 RISK FACTORS
 Heredity
 Organic brain disease, particularly basal ganglia d/os.
 Substance use d/os, particularly GABA-ergic drug withdrawal
 Low serum iron
 ? Male> females; young > old
 Previously speculated to be related to muscle mass
 Actual average age of patients with NMS is 40

 Physiological states: Agitation ; Dehydration

 Historical variables: History of NMS
 30-33% of NMS patients when rechallenged
 17% of NMS patients report similar past episodes
 History or current episode of catatonia
 RISK FACTORS CONT…
 Pharmacologic variables
 High potency
 High dosage
 Rapid dose escalation
 ? Intramuscular route: Unclear if IM injections convey extra risk
or simply contribute to elevated CK
 Depot neuroleptics: Longer duration
 Concomitant medications: multiple antipsychotics, non-
neuroleptic medications, anticholinergics.
 Abrupt cessation of dopamine agonist e.g., anti-parkinson’s
medications, bupropion
 Abrupt cessation of antipsychotic; “Withdrawal NMS”
 CLINICAL CHARACTERISTICS
 Develops quickly over hours to days

 Early signs

 Change in mental status

 Catatonia
 Extrapyramidal symptoms unresponsive to antiparkinsonian agents

 Autonomic dysfunction
CLINICAL CHARACTERISTICS
CONT…
Other Signs and Symptoms
 Hyperthermia: 98%

 Muscle rigidity - “lead pipe rigidity”: 97%

 Delirium and/or catatonia: 97%

 Autonomic dysfunction
 Tachycardia: 88%
 Profuse diaphoresis
 Labile blood pressure: 61%
 Tachycardia or labile blood pressure: 95%
CLINICAL CHARACTERISTICS
CONT…
Laboratory findings
 Rhabdomyolysis (↑ CPK)
 Leukocytosis
 Low serum iron
 Metabolic acidosis
 D-dimers
 LDH
 Electroencephalogram often consistent with delirium
 Neuroimaging typically normal
 DIFFERENTIAL
DIAGNOSIS
 Most common disorders mistaken for NMS
 Malignant or non-malignant catatonia
 Delirious mania (aka Bell’s mania, manic delirium)
 Agitated delirium
 Serotonin Syndrome
 Malignant hyperthermia
 “Benign” extrapyramidal side effects (EPS)
 Infections
 Seizures
 Thyrotoxicosis
 Pheochromocytoma
 Heatstroke (Exertional or classic)

40
 OUTCOMES
Mortality
 6% as of 2015

 Risks for increased mortality

 Older age
 Higher temperatures
 Depot neuroleptics (?)
 Pre-existing brain pathology
 Development of renal failure

41
OUTCOME CONT…
Morbidity
 Renal insufficiency/failure: 16-25%

 Respiratory failure

 Cardiac morbidity

 Possibility of cognitive sequelae, though long-term

cognitive effects seem rare
- May be the result of hypoxic injury.
 TREATMENT OF NMS
 Basics

 Early recognition

 Cessation of neuroleptics

 Re-introduction of dopamine agonists if removed

 Hydration

 Temperature reduction

 Intensive monitoring

 Supportive care

43
 TREATMENT OF NMS CONT…
 Benzodiazepines
 NMS is thought to represent an iatrogenic malignant catatonia
 Benzodiazepines reduce rigidity and treat catatonia
 Intravenous lorazepam is preferred
 Easily administered
 Rapid onset of action
 Longer effective length of action
 Preference for GABA-B receptor
 High doses (18-24mg daily) often required and tolerated
 If IV route is not an option, IM>sublingual>PO

44
TREATMENT OF NMS CONT…
 Dantrolene

 Muscle relaxant

 81% of patients benefit in some studies

 1-10mg/kg/day in divided doses

 Optimal length of treatment not established

 May cause hepatic and respiratory compromise

45
 TREATMENT OF NMS CONT…
 Dopaminergic medications
 Bromocriptine
 94% found benefit as monotherapy
 Shortened time to clinical response
 2.5mg tid - 15mg tid
 Amantadine
 63% found benefit as monotherapy
 200-400 mg/day
 Levodopa

 All dopaminergic medications carry risk of worsening

underlying psychosis

46
 TREATMENT OF NMS
CONT…
 ECT
 Definitive treatment
 May increase dopamine synthesis and release
 ECT considered if…
 Unresponsive to pharmacologic treatment in first 24-48
hours
 Prominent features of catatonia or severe rigidity
 Psychosis develops following NMS
 Mean time to response is ± 1.46 - 2.38 days

47
 TREATMENT GUIDELINES FOR NMS

 Mild or early NMS

 Supportive care and benzodiazepines

 Moderate NMS (rigidity and temperatures 38-40)

 High-dose benzodiazepines; consider dopamine agonist

 Severe NMS (rigidity, hypermetabolism, temperatures >40°)

 High-dose benzodiazepines
 Early consideration of ECT
 Dantrolene

48
 ANTIPSYCHOTIC
RECHALLENGE FOLLOWING
NMS
 Recurrence rate may be as high as 30-50%
 Inversely related to time to rechallenge.

 Guidelines for rechallenge

 Reduce potential risk factors
 Two weeks from resolution of NMS
 Gradual titration of low starting doses
 Use lower potency or atypical antipsychotics
 Ideally rechallenge should occur in a hospital
 Successful cases of clozapine rechallenge following clozapine-
induced NMS, but some cases recur

49
SEROTONIN
SYNDROME
 SEROTONIN SYNDROME
 Serotonin syndrome can be a serious complication of treatment
with SSRIs, TCAs, MAOIs, and other serotonergic medications
 It usually occurs when 2 or more serotonin-modifying agents are
used in combination or in overdose settings
 Cases have been reported after single agent therapy

 Incidence unknown
 Significantly underdiagnosed because of variable
symptomatology

51
 PATHOPHYSIOLOGY
 Enhanced central serotonergic activity

 The excessive serotonergic activity may influence other parts of

the CNS
 Dopamine
 Norepinephrine

 Receptors
 Hyperstimulation of the 5-HT1A receptors

52
CLINICAL CHARACTERISTICS
Clinical triad 3. Neuromuscular
1. Cognitive/behavioral abnormalities
alterations  Myoclonus
 Delirium  Hyperreflexia
 Catatonia  Rigidity
 Agitation
 Lethargy  Coma
2. Autonomic instability
 Hyperthermia
 Tachycardia
 Diaphoresis
 Dilated pupils

53
 CLINICAL CHARACTERISTICS
 No specific tests available for diagnosis

 Blood levels of serotonin do not correlate with clinical

findings

 Nonspecific laboratory findings may include…

 Elevated total WBC count, CPK levels, and transaminases.
 Decreased serum bicarbonate level

 Severe cases can evolve to include…

 Disseminated intravascular coagulation, rhabdomyolysis, and
metabolic acidosis
 Renal failure and myoglobinuria
 Adult respiratory distress syndrome
54
 RISK FACTORS
 Risk factors
 Administration of >/=2 serotonergic medications
 Overdose
 Use of lithium?
 Rarely with monotherapy
 Pharmacodynamic interactions
 Pharmacokinetic interactions

 The most common implicated drug combinations

 MAOI and SSRI or another serotonergic agent
 Now much more commonly 3-6 serotonergic agents
 E.g., SSRI + trazodone + tramadol + buspirone
 Overdose on SSRI, SNRI, atypical antipsychotic or
combination 55
 RISK FACTORS
 Mechanisms that lead to overstimulation of serotonin
 Increased precursors of serotonin or its agonists
 Buspirone, L-dopa, lithium, LSD, L-tryptophan, trazodone

 Decreased serotonin metabolism

 MAOI – irreversible (phenelzine, tranylcypromine, selegiline)
 MAOI – reversible (linezolid)

 Increased serotonin release

 Amphetamines, cocaine, MDMA (“ecstasy”), fenfluramine, reserpine

 Inhibit serotonin reuptake

 SSRI, SNRIs, TCAs, meperidine, tramadol

56
 DIFFERENTIAL DIAGNOSIS
 Most common disorders mistaken for Serotonin Syndrome
 SSRI discontinuation syndrome
 Catecholamine excess
 Anticholinergic toxodrome
 Alcohol and substance withdrawal states
 Infections
 Toxic-metabolic delirium
 Extrapyramidal side-effects
 NMS
 Pheochromocytoma
 Carcinoid tumor

57
 CLINICAL COURSE AND
OUTCOMES
 Clinical course and outcome
 Rapid onset
 Usually self-limited, with an uneventful resolution, once the
offending agent has been discontinued
 No data for rechallenge

 Clues to Serotonin Syndrome

 Look for it in every case of overdose
 Look for it in any patient on >4 psychiatric medications
 Consider it in all catatonic patients
 Keep an eye out for the twitchy patient

58
 TREATMENT
 No standardized treatment exists.

 Management starts with early recognition of the syndrome, and

supportive care

 The basic treatment of serotonin syndrome consists of

 Discontinuation of the causative drugs
 Supportive therapy
 Hydration
 Cooling
 Medications
 Benzodiazepines
 Cyproheptadine

59
 TREATMENT
 Benzodiazepines
 May blunt the hyperadrenergic component of the syndrome
 Help with catatonic features
 Act as muscle relaxants
 Help with agitation

60
 TREATMENT CONT…
 Cyproheptadine
 First-generation antihistamine with serotonin antagonist
properties.

 Often not necessary

 Mechanism
 5-HT1A and 5-HT2 receptor antagonists

 Dose
 May consider an initial dose of 12mg followed by 2mg
every 2 hours if symptoms continue
 Maintenance dosage is 8mg every 6 hours

61
 TREATMENT CONT…

 Chlorpromazine
• Shown to be effective in some cases in the treatment of
serotonin syndrome
• Mechanism
• Fairly potent 5-HT2 and 5-HT1A receptor antagonist
• Advantages
• It can be administered via an IM injection
• Disadvantages
• It can cause hypotension, dystonic reactions, and
increase risk for NMS

62
 ACUTE DYSTONIAS
 Dystonias are brief or prolonged contractions of muscles that result
in obviously abnormal mov’ts or postures

 Common side effect of treatment with 1st gen antipsychotics

 Over 95% occur within the first 4 days of therapy.

 Occur in 10% of pts and is a/w higher doses of meds especially in

younger, male pts than older.

 Pathophysiology; Dopaminergic hyperactivity in the basal ganglia

when CNS levels begin to fall between doses
PRESENTATION
ACUTE DYSTONIA MANAGEMENT
 Parenteral anticholinergic meds (benzotropine- 1-2mg) or
antihistamines (diphenhydramine-50 mg, promethazine 25-
50mg im): relief within 15 minutes.
 Dose can be repeated in 20-30 minutes if needed

 If no improvement occurs in 20-30 minutes after the second

dose, a benzodiazepine (Lorazepam-1-2 mg) should be given
I.M. or I.V.

 Prophylactic use of anticholinergics is also encouraged in

patients who have had an episode of dystonia and this can be
continued for 4-8 weeks and tapered over 1-2 weeks
REFERENCES
 Kaplan & Saddock’s , Synopsis of Psychiatry 11th Edition,
Lippincott Williams & Wilkins/ Wolters Kluwer

 Practice Guideline for the Assessment and Treatment of

Patients with Suicidal Behaviors. American Journal of
Psychiatry (Suppl.) Vol. 160, No. 11, November 2003.