Psychiatric EmergenciesPaul ScavellaUniversity of the West IndiesPsychiatry Clerkship18/03/2016

DefinitionsEmergency – unforeseen combination of

circumstances which calls for immediate action

Medical emergency – defined as a medical condition which endangers life and/or causes great suffering to individual

Psychiatric – disturbances of thought, affect and psycho motor activity threat to his/her person or people in the environment◦Adjunct side effects from medication

Definition cont’dPsychiatric Emergencies require immediate evaluation by a Psychiatrist to determine the nature and severity of the condition.

Note: Psychiatric Emergencies may affect both adults and children.

CharacteristicsAny condition/situation making

the patient and relatives seek immediate treatment

Disharmony between the patient and environment

Sudden disorganisation in personality ◦Affecting socio-occupational

functioning

Objectives for emergency interventionSafeguard the life of the patientReduce anxiety of familyEnhance emotional security of

others in the environment

Types of Psychiatric Emergencies Suicide or deliberate self harm Violence/Excitement Stupor Panic Withdrawal Sx of drug dependence

◦ Delerium Tremens Alcohol or drug overdose Epilepsy or Status Epilepticus Severe Depression Iatrogenic emergencies

◦ Side effects of psychotropic drugs◦ Psychiatric complications of drugs used in medicine

Abnormal response to a stressful situation

General guidelines of management for Psychiatric Emergencies1. Handle with utmost tact and

speech so that well being of other patients is not affected

2. Act in a calm manner to prevent other clients from getting anxious

3. Shift the client as early as possible to a room where they can be safe guarded against injury

General guidelines of management for Psychiatric Emergencies4. Ensure that all other clients are

reassured and that routine activities proceed normally

5. Psychiatric emergency overlap medical emergencies and staff should be familiar with both

EpidemiologyIn the USA, Psychiatric Emergency Rooms are used equally

by men and by women and are used by more single than married individuals

About 20 % of the patients are suicidal and 10% are violent.

The more common diagnoses are mood disorders, schizophrenia and Alcohol Dependence.

40% of persons need hospitalization.

Most visits occur during the nights.

Psychiatric Emergencies are NOT increased during full moon or Christmas season.

PrevalenceRate of psychiatric emergencies

in non-psychiatric institutions estimated at anywhere from 10% - 60%

All physicians need basic knowledge of the diagnostic and therapeutic steps to be taken in psychiatric emergencies

Treatment settingsMost emergency psychiatric evaluations are

done by non-psychiatrists in a general medical emergency room setting (like in the Bahamas), but specialized psychiatric services are increasingly favored.

Regardless of the type of setting, an atmosphere of safety and security must prevail.

An adequate number of staff members, including psychiatrists, nurses, aides and social workers must be present at all times.

Treatment settings Immediate access to the medical emergency room

and to appropriate diagnostic services is necessary because one third of medical conditions present with psychiatric manifestations.

Ideally, the full spectrum of psychopharmacological options should be available to the psychiatrist.

Whenever possible, agitated and threatening patients should be sequestered from the nonagitated.

Seclusion and restraint rooms should be located close to the nursing station for observation.

EvaluationPrimary goal is timely

assessment of the patient in crisis

Physician must ◦Make an initial diagnosis◦Identify precipitating factors and

immediate needs◦Begin treatment or refer to the most

appropriate treatment setting

Evaluation

EvaluationThe standard psychiatric

interview consisting of a history, mental status exam, when appropriate and depending on the emergency room, a full physical and ancillary tests

For Psychiatric emergencies, the physician must be able to introduce modifications as needed.

EvaluationThe emergency evaluation should

address the following:◦Is it safe for the patient to be in the

Emergency room?◦Is the problem organic, functional or

a combination?◦Is the patient psychotic?◦Is the patient suicidal or homicidal?◦To what degree is the patient capable

of self-care?

Medical or PsychiatricConditions such as DM, Thyroid disease,

acute intoxications, withdrawal states, AIDS and head traumas can present with prominent mental status changes that mimic common psychiatric illnesses

Such conditions may be life-threatening if not treated promptly

Sometimes once labeled psychiatric patients with mental illnesses may be overlooked and deteriorate clinically

Features that point to medical cause of a mental disorderAcute onset (within hours or minutes,

with prevailing)First episodeGeriatric ageCurrent medical illness or injurySignificant substance abuseNon-auditory disturbances of perceptionNeurological symptoms – LOC, seizures,

head injury, change in headache pattern, change in vision

Specific Interview SituationsPsychosis – physicians must be prepared to

structure or terminate an interview to limit the potential of agitation or regression

Depression and potentially suicidal – should always ask about suicidal ideas as part of every MSE, especially if the patient is depressed

Violent patients – may be violent for many reasons; must attempt to ascertain the underlying cause of the violent behaviour as cause determines intervention

History signs and symptoms of suicidal riskPrevious attempt or fantasized suicideAnxiety, depression, exhaustionAvailability of means of suicideConcern for effect of suicide on family

membersVerbalised suicidal ideationPreparation of will, resignation after agitated

depressionProximal life crisis, such as mourning or

impending surgeryFamily History of suicidePervasive pessimism or hopelessness

Treatment goals

Treatment of EmergenciesPsychotherapy

◦In an emergency psychiatric intervention, all attempts are made to help patient’s self-esteem

◦Empathy is always important◦No single approach is appropriate for

all persons in similar situations◦When clinician does not know what

to say listening is best

Treatment of EmergenciesPharmacotherapy

◦Major indications for the use of psychotropic medication in emergency room include: Violent or assaultive behaviour Massive anxiety or panic Extrapyramidal reactions such as

dystonia and akathisia Note laryngospasm is a rare form of dystonia

and psychiatrists should be prepared to maintain on open airway wit intubation

Treatment of EmergenciesRestraints

◦Used when patients are so dangerous to themselves or others that they pose a severe threat that cannot be controlled in any other way

◦Patients may be restrained temporarily to receive medication or if medication cannot be given

Tips when using restraints Preferrably 5 or a minimum of 4 persons should be used

to restrain the patient (leather are safest type) Explain to the patient why he or she is going into

restraints A staff member should always be visible and reassuring

the patient Reassurance helps alleviate the patient’s fear of

helplessness, impotence and loss of control Patients should be restrained with legs spread-eagled

and one arm to one side and the other over the patients head. IV’s should be placed in the event they need Fluids or medication

Should be checked periodically for safety and comfort Document reason for the restraints, course of treatment

and response to treatment with restraints

Treatment for EmergenciesDisposition

◦In some cases admitting or discharging the patient is not optimal

◦Some conditions have to be managed in an extended-observation setting, e.g., adjustment reaction to a traumatic event

◦Best to admit patient voluntarily, however very difficult to

SuicideOne of the commonest

psychiatric emergenciesCommonest cause of death

among psychiatric patientsDefined as the intentional taking

of ones life in a culturally non-endorsed manner

Suicide Aetiology1. Psychotic Disorder

◦ Major Depression◦ Schizophrenia◦ Substance abuse◦ Dementia◦ Delirium◦ Personality disorder

2. Physical Disorder◦ Chronic or incurable physical disorders like Cancer, AIDS

3. Psychosocial Factors◦ Failure in exams◦ Marital problems◦ Loss of loved one or object◦ Isolation and alienation from social groups◦ Financial & Occupational difficulties

SuicideRisk Factors

◦ Age > 40 ◦ Male gender◦ Single◦ Previous attempts◦ Depression: Higher risk after response to

treatment, Higher risk in week after discharge◦ Suicidal preoccupation◦ Alcohol or drug dependence◦ Chronic illness◦ Recent serious loss or major stressful life event◦ Social isolation◦ Higher degree of impulsivity

ManagementBe aware of the warning signsMonitor the patient’s safety

needsAcute psychiatric interviewCounseling & Guidance

◦Deal with ongoing life stressors and teach new coping skills

Treatment of psychiatric disorders

Violence/Excitement/Aggressive BehaviourPhysical aggression by one

person on anotherDuring this stage patient will be

irrational, uncooperative, delusional and assaultive

Violence/Excitement/Aggressive Behaviour: AetiologyOrganic Psychiatric Disorders

◦ Delirium◦ Dementia◦ Wernicke – Korsakoff psychosis

Other pyschiatric disorders◦ Schizphrenia◦ Mania◦ Agitated depression◦ Substance withdrawal◦ Epilepsy◦ Acute stress reaction◦ Panic disorder◦ Personality disorder

Violence/Excitement/Aggressive Behaviour: ManagementReassuraneSedation if necessary

◦Diazepam 5 – 10 mg slow IV◦Haloperidol 2 – 10 m IM/IV◦Chlorpromazine 50 – 100 mg IM

Collect detailed history and explore causeComplete physical examProvide care and do due diligencePhysical restraints – last resort

Stupor & Catatonic SyndromeClinical syndrome of akinesis and

mutism often associated with catatonic signs and symptoms

Catatonic synd. Any disorder which presents with at least 2 catatonic signs◦Negativism, mutism, stupor,

ambitendency, echolalia, echopraxia, stereotypes, verbigeration, excitement and impulsiveness

Stupor & Catatonic Syndrome: ManagementEnsure patient airwayMaintain hydrationHistory and PEAncillary investigations before

starting treatmentProvide care for unconscious

patient◦Skin, nutrition, elimination, personal

hygiene

Panic AttacksEpisodes of acute anxiety and

panic occurs as part of psychotic or neurotic illness

Manifestations◦Palpitations (Anxiety MCC)◦Sweating, tremors, feeling of

impending death◦Chest pain, nausea, abdominal

distress◦Paresthesia, Hot flushes

Panic Attacks: ManagementGive reassuranceFind causeInjection of Diazepam 10mg or

lorazepam 2 mg in acute settingCounsel patient and relativesCognitive Behavioural therapy

Victims of DisasterPeople who have survived a

sudden, unexpected, overwhelming stress

FeaturesAnger, Frustration, GuiltsNumbness, ConfusionFlashbacks, Depression

Victims of Disaster: ManagementTreatment of the life-threatening

physical problemIntervention

◦Listen attentively, don’t interrupt◦Acknowledge understaning of the pain and

distress◦Console if appropriate (pat on the shoulder)◦Don’t ask them to stop crying

Group therapyBenzodiazepines can be given to reduce

anxiety

Hysterical AttacksA hysteric may mimic

abnormality of any function which is under voluntary control◦Hysterical fits◦Hysterical ataxia◦Hysterical paraplegia

Hysterical attacks: ManagementHelp patient realise the meaning

of the symptoms and help them find alternative ways of coping with stress

IV pentothal is usefulRelieve anxiety amonth family

members

Delirium TremensLife threatening alcohol

withdrawal syndrome – peaks a days 2 to 5 after last drink

Characterised by delirium, hyperthermia, tachycardia, seizures

ALCOHOL WITHDRAWAL TIMELINE

TIME

6 to 8 hours

8 to 12 hours

12 to 24 hours

During 72 hours but can be up to one week.

SYMPTOMS

TREMULOUSNESS (shakes or jitters)

Psychotic and perceptual symptoms

Seizures

Delirium Tremens (DTs)

Delirium Tremens: ManagementBest treatment for DTs is prevention.Once Delirium sets in, IV benzodiazepines is best eg,

Lorazepam IV at 0.1mg/kg or if available chlordiazepoxide (librium), should be given orally every 4 hrs

Antipsychotic medications that may reduce the seizure threshold in patients should be avoided.

High calorie, high-carbohydrate diet supplemented by Multivitamins is important.

Be careful with physical restraints, and remember hydration is essential.

Warm, supportive psychotherapy in the treatment of DTs is essential since patients are often frightened and anxious.

Epileptic FurorFollowing an epileptic attach

patient may behave strangely and become excited or violent

Management◦Diazepam 10 mg IV◦Haloperidol 10 mg IV

Drug Adverse EffectsNeuroleptic Malignant Syndrome

– AE of Antipsychotics◦FEVER mnemonic◦Fever◦Encephalopathy◦Elevated Enzyme (CK) and WBCs◦Rigidity

Drug Adverse EffectsNMS Management

◦Stop the causative drug◦Cool the patients body temp◦Maintain fluid and electrolyte blance◦Dantrolene

Drug Adverse EffectsSerotonin Syndrome

The diagnosis is usually made by asking questions about your medical history, including the types of drugs the patient takes.

To be diagnosed with serotonin syndrome, you must have been taking a drug that changes the body's serotonin levels (serotonergic drug) and have at least three of the following signs or symptoms:

Agitation, Diarrhea ,Heavy sweating not due to activity Fever

Mental status changes such as confusion or hypomania

Muscle spasms (myoclonus), Hyperreflexia ,Shivering, Tremor AND Uncoordinated movements (ataxia)

Serotonin Syndrome: Management Benzodiazepines such as diazepam (Valium) or

lorazepam (Ativan) to decrease agitation, seizure-like movements, and muscle stiffness

Cyproheptadine (Periactin), a drug that blocks serotonin production

Fluids by IV

Withdrawal of medicines that caused the syndrome

In life-threatening cases, paralytics and intubation may be necessary to avoid further damage.

Drug Adverse Effects: Lithium Benzodiazepines such as diazepam (Valium) or

lorazepam (Ativan) to decrease agitation, seizure-like movements, and muscle stiffness

Cyproheptadine (Periactin), a drug that blocks serotonin production

Fluids by IV

Withdrawal of medicines that caused the syndrome

In life-threatening cases, paralytics and intubation may be necessary to avoid further damage.