Psychiatric emergencies are acute changes in behavior that negatively impact a patient's ability to function in his or her environment. ... The screening assessment also involves a psychiatric safety check to explore for suicidal ideation, homicidal ideation, or patients' inability to care for themselves.
2. Objectives
At the end of the class the students are able to
ā¢ Define Psychiatric emergencies
ā¢ Enlist the types of psychiatric emergencies
ā¢ Enumerate etiology of psychiatric emergencies
ā¢ Explain the management of different types of
psychiatric emergencies
3. Emergency
ā¢ It is defined as an unforeseen combination of
circumstances which calls for an immediate action.
ā¢ Medical emergency: it is defined as a medical
condition which endangers life or causes great
suffering to the Individual.
4. Psychiatric Emergencies
ā¢ A condition where the patient has disturbances of
thought, affect and psychomotor activity which
causes sudden distress to the individual or sudden
disability, thus requiring immediate management.
ā¢ Needs immediate intervention
ā To safeguard the life of pt. & others
ā Reduce anxiety of family members
ā to enhance emotional security to others in the
environment
6. SUICIDAL THREAT/ ATTEMPT
ā¢ Commonest emergency in psychiatry's.
ā¢ Commonest cause of death among psychiatric patient
ā¢ Deliberate self harm(DSH)
ā¢ Defined as intentional human act of killing oneself OR Self inflicted
cessation(death). It ends with fatal outcomes.
ā¢ Attempted suicide: is an unsuccessful suicidal act with non-fatal outcome.
ā¢ Believed that 2-10% of all persons who attempt suicide, eventually complete
suicide in next 10 years.
ā¢ Suicidal gesture: (suggesting a cry for help) , is an attempted suicide where the
person performing the action never intends to die by the act.
ā¢ Crime by law
Etiology
ā¢ Psychiatric disorders ā major depression, schizophrenia, drug & alcohol abuse,
dementia, delirium, personality disorder
ā¢ Physical disorders ā incurable, painful physical conditions like cancer, AIDS
etc.
ā¢ Psychosocial factors ā Failures, losses, dowry harassment, marital problems,
isolation & alienation from social groups, financial & occupational difficulties
7. ā¢ Psychological theory:
Acc to Freud:
ā¢ Anger turned inward
ā¢ Hopelessness
ā¢ Desperation & guilt
ā¢ h/o aggression and violence
ā¢ Shame & humiliation
ā¢ Developmental stressor-conflict, separation, rejection, economic problems, medical illness.
ā¢ Socio-logical theory:
Acc to Durkheim : three categories
1) Egoistic suicide : individual who feels separate &apart from the main stream of society.
integration is lacking. Individual doesn't feel a part of group.
2). Altruistic suicide: is opposite of egoistic suicide. Individual is excessively integrated to
society/ in to the group.
3). Anomic suicide: occurs in response to changes that occur in an individualās life (eg.
Divorce, loss of job) that disrupt feelings of relatedness to the group.
ā¢ Biological theories:
1) Genetics
2) Neurochemical factors- decreased serotonin
8. Risk Factors
ā¢ Males > 40 years of age
ā¢ Females > 55 yrs
ā¢ Men > women
ā¢ Men ā greater risk of completed suicide
ā¢ Women ā greater risk of attempted suicide
ā¢ H/o suicide attempts
ā¢ Recent losses
ā¢ Social isolation
ā¢ Suicidal pre-occupation (suicide note)
ā¢ Alcohol or drug dependence.
ā¢ Marital status: single person is twice. Divorced, separated, or
widowed person have 4-5 times greater risk than married.
ā¢ Highest & lowest social classes have higher suicide rates.
ā¢ Ethnicity: whites are at highest risk for suicide .
9. Methods used
ā¢ Acc to ( NCRB 2003),COMMONEST MODES ARE:
ā¢ Ingestion of poison (38.4%)
ā¢ Hanging( 29.4%)
ā¢ Burning ( 11%)
ā¢ Drowning( 9%)
ā¢ Jumping in front of train or another vehicle (3%)
ā¢ Men are using more violent methods for suicide as
compared with women.
10. Management
ā¢ Beware of ā
ā Suicidal threats
ā Writing farewell letters
ā Giving away treasured articles
ā Closing bank accounts
ā Appearing peaceful and happy after a period of
depression
ā Refusing to eat or drink, maintain personal
hygiene
11. Management
ā¢ Monitor for ā
ā Take threats & attempts seriously & notify psychiatrist
ā Store drugs out of reach of pt
ā Remove sharp objects from pt.ās environment
ā Remove straps & clothing that can be used for
strangulation
ā No door bolts from inside for pt.
ā Somebody to accompany pt. to bathroom
ā Constant observation ā never leave alone
ā Good vigilance ā specially during morning hrs
ā Spend time with pt, talk to pt and encourage to ventilate
feelings
12. ā Encourage him to talk about suicidal plans/
methods
ā Sedation in cases of severe suicidal tendencies
ā Encourage verbal communication about suicidal
thoughts, fear & depressive thoughts
ā Enhance self-esteem by focusing on strengths
ā Positive feedback, realistic praise and appreciation
for change to be given
13. Steps for preventing suicide
ā¢ Take all the suicidal threats, gestures, /attempts seriously and notify a psychiatrist
or a mental health professional.
ā¢ Psychiatrist should quantify the seriousness of the situation & take remedial
precautionary measures.
- inspect physical surroundings & remove all means of committing suicide like
sharp objects, ropes, drugs, firearms etc. search the patient thoroughly.
- surveillance, depending upon the severity of risk.
ā¢ Acute psychiatric emergency interview
ā¢ Counseling & guidance ā to deal with the desire to attempt suicide, to deal with
ongoing life stressors, & teaching coping skills & interpersonal skills.
ā¢ Treatment of the psychiatric disorder with medication, psychotherapy/ECT.
ā¢ Follow up care is very important to prevent future suicidal attempts or suicide.
14. Management of attempted suicide
ā¢ Hospitalize the patient.
ā¢ Record vital signs
ā¢ Life saving measures depending on the physical condition of
the patient.
ā¢ Prevent regurgitation
ā¢ Start IV line
ā¢ Manage the shock
ā¢ Address medico-legal issues
ā¢ Discuss with other staff & reassure them
ā¢ Care of other pts ā shift them away, engage in games or
recreational activities, serve food, medication earlier than
schedule, observe for any change in behaviour & report
promptly
15. 2. Violent/Aggressive behavior
ā¢ this is severe form of aggressiveness, pt is irrational, uncooperative,
delusional and assaultive.
ā¢ Violence and assaultive behavior are difficult to predict .The best
predictors of potential violent behavior are:1) excessive alcohol
intake 2) a h/o violent acts with arrests or criminal activity 3) h/o
childhood abuse.
ļ Signs of impending violence:
- Recent acts of violence, including property violence, verbal or
physical threats.
- Carrying weapons or others used as a weapon( forks)
- Progressive psychomotor agitation
- Alcohol or substance intoxication
- Paranoid features in a psychotic patient
- Command violent auditory hallucinations
- Brain diseases
- Catatonic excitement, certain manic episodes etc.
17. Management
Assess the risk for violence:
- Consider violent ideation, wish, intention, plan, implementation of
plan.
- Consider demographics- gender (male), age (15-24), socioeconomic
status(low), social support (few).
- Consider the patientās history: violence, non-violent antisocial acts,
impulse dyscontrol (gambling, substance abuse, suicide, psychosis)
- Consider overt stressors ( marital conflicts, real or other loss).
- Management
ā¢ Hospitalize the pt.
ā¢ Reassurance-trustworthy relationship with patient.
ā¢ Remove the ties ā a large amt of aggression is diffused by allowing freedom
ā feels less humiliated
ā¢ Talk down ā be firm but kind
ā¢ Chemical restraints ā sedation(diazepam- 5-10 mg IV Slowly, lorazepam 1-2
mg IV slowly).
ā¢ Collect history from relatives, rule out organic pathology ā H/o convulsions,
fever, recent intake of alcohol, fluctuations of consciousness
18. ā¢ Carry out complete physical examination
ā¢ Perform routine investigations
ā¢ Look for dehydration, malnutrition
ā¢ Start IV drip
ā¢ Minimum furniture in the room
ā¢ Remove sharp objects, ropes, glass items, ties, strings, match boxes
etc. from ptās unit
ā¢ Minimum environmental stimuli, limited visitors
ā¢ Remove hazardous objects and substances
ā¢ Be with the pt & give a sense of security to pt
ā¢ Encourage the pt ātalk outā aggressive feelings
ā¢ Physical restraints only on prescription( leather belts, padded
bandages ect).
ā¢ Meet nutritional and elimination needs of the pt
ā¢ Involve the patient in activities which he enjoys.
ā¢ Emphasize that he is a respected person but violence is unaccepted.
19. Guidelines for self protection
ā¢ Never be alone with the patient
ā¢ Keep a arm length distance from the pt always
ā¢ Be alert & prepared to move
ā¢ Maintain a clear exit route for both the staff & pt.
ā¢ Ensure no weapons with patient.
ā¢ If the pt. has weapon, ask him firmly to keep it on
table or floor
ā¢ Never attempt to snatch it from the patient
ā¢ Distract the pt momentarily to remove the weapon
ā¢ Give prescribed antipsychotic after physically
restraining
ā¢ Never turn back to the patient.
20. 3. Panic attack
ā¢ Severe form of acute anxiety
may lead the person to be
panic, occurs as a part of
psychotic or neurotic illness
ā¢ It is characterized by
spontaneous, episodic & intense
periods of anxiety usually lasts
for few min.
ā¢ Common Symptoms are:
ā¢ Palpitations
ā¢ Sweating,
ā¢ tremors,
ā¢ feelings of choking,
ā¢ chest pain, nausea,
ā¢ abdominal distress,
ā¢ fear of dying,
ā¢ Paresthesia( tingling sensation)
ā¢ chills or hot flushes
Management of Panic Attack
ā¢ Reassure the patient.
ā¢ Search for causes
ā¢ Diazepam 10 mg or lorazepam 2 mg to calm down
21. ā¢ Behavioral therapy
ā¢ Relaxation therapy
ā¢ Drug therapy: Phenobarbitones sodium 100 mg IM
ā¢ Aprazolam(.25-.5 mg orally), lorazepam( 1-2 mg)
ā¢ EST
ā¢ If the patient is un-cooperative, tense, fainting, act in a calm & quite manner.
ā¢ Advise patient to avoid or reduce the use of coffee, alcohol intake & smoking.
ļ Use of 5 Rās:
- Recognition of cause
- Relationships are identified for support & help
- Relaxation through medication, massage, breathing exercises etc.
- Removal of threat or stressors
- Re-engagement/motivation.
22. 4. Catatonic Stupor
Stupor: It is a state of diminished consciousness in which patient
remains mute & still although eyes remains open & may
follow external object. Its seen in catatonia & depression.
ā¢ Clinical syndrome are:
ā¢ Mutism, negativism, stupor, ambitendency, echolalia, echopraxia, automatic
obedience, posturing, mannerism, stereotypes, etc.
Management of Catatonic stupor
ā¢ Ensure patent airway
ā¢ Administer IV fluids
ā¢ Collect history & perform physical examination, neurological exmn, to exclude
intracranial cause. E.g. Brain hemorrhage.
ā¢ Routine investigations
ā¢ Check cardiac functions
ā¢ Give attention to bowel, bladder, oral cavity, bed sores.
ā¢ Minimum dose of antidepressants
ā¢ Provide calm & secure environment
ā¢ Prepare the patient for ECT if require
ā¢ Observe the records & vital signs of the patient
ā¢ Care of the unconscious patients
23. 5. Hysterical Attack
Hysteria: attention seeking behavior, repressed anxiety,
transformation of an unconscious conflict in to physical
symptoms, such as paralysis, blindness, loss of sensation ect.
Common modes of present action are:
ā¢ Hysterical fits, hysterical ataxia(loss of control over bodily movements), hysterical
paraplegia( all or part of the trunk, legs, pelvic organ)
ā¢ Marked by dramatic quality & sadness of mood
Management
ā¢ Hysterical fits are distinguish from true / genuine fits
ā¢ Explain the psychological nature of disease to the relatives of the patient
ā¢ Reassure the family members that no harm would come to pt.
ā¢ Help the pt to recognize the meaning of symptoms & identify suitable alternative
coping mechanism
ā¢ Observe the patient continuously
ā¢ Suggestion therapy with IV pentothal, helpful in some cases.
24. 6. ALCOHOL INTOXICATION
ā¢ Also called as pathological intoxication
ā¢ Acute intoxication develops during or shortly after alcohol
ingestion.
Clinical manifestations of alcohol intoxication are:
- Maladaptive behavior
- Inappropriate sexual behavior
- Aggression
- Slurred speech
- In coordination
- Impaired memory
- Coma, stupor.
25. Management
ā¢ Take careful h/o patient & family
ā¢ Check the level of alcohol in blood regularly
ā¢ The signs are obvious at blood level of 150-200
mg% . Death can occur at level 400-8oo mg %
ā¢ Symptomatic management
ā¢ Start IV fluids
26. 7. LITHIUM TOXICITY
ā¢ The toxic effects of lithium can be seen at blood levels
above 2 mEq/l . It affects the CNS, thyroid, kidneys, GIT.
ā¢ The symptoms of toxicity are:
- Tremor
- Ataxia
- Nystagmus
- Confusion
- Diarrhea
- Vomiting , drowsiness, unsteadiness.
27. Management
ā¢ Immediately stop lithium therapy
ā¢ Replace fluid & electrolytes
ā¢ Dialysis may be needed in severe toxicity
ā¢ Enhance lithium excretion
ā¢ Management of symptoms are done accordingly
e.g. Dry mouth- give sips of water to patient
- Maintain oral hygiene of patient
- GI upset: make schedule for eating, start IV.
- Tremors: donāt leave the patient alone, advise the patient to take rest
- Polyuria, dehydration: maintain intake/ output chart of patient.
28. 8. Transient Situational Disturbances
ā¢ Characterized by disturbed feelings &
behavior occurring due to overwhelming
external stimuli
Management
ā¢ Reassure
ā¢ Mild sedation
ā¢ Allow the pt to ventilate
ā¢ Counseling by trained professionals
29. 9. Delirium tremens
ā¢ A condition resulting from withdrawal of alcohol:
ā¢ Clouding of consciousness with disorientation.
ā¢ Poor attention span and distractibility
ā¢ Hallucination, illusions(visual, auditory, tactile)
ā¢ Autonomic disturbance with tachycardia, fever., sweating, hypertension.
ā¢ Insomnia
ā¢ Dehydration with electrolyte imbalance
ā¢ Death, if occurs, is often due to: cardiovascular collapse, infection,
hyperthermia or self-inflicted injury.
Management
ā¢ Keep in safe quiet environment
ā¢ Symptomatic management
ā¢ Sedation with diazepam
ā¢ Maintain fluid & electrolyte balance
ā¢ Reassure the pt & family
30. 10. Epileptic Furor
ā¢ Strange ā excited or violent behavior of the pt
following epileptic attack
Management
ā¢ Sedation
ā¢ Haloperidol to reduce psychotic behaviour
31. 11. Acute Drug-Induced EP Syndrome
ā¢ Acute symptoms resulting from side effects of
antipsychotic medications ā EPS
ā¢ Neuroleptic malignant syndrome ā rare but
serious
Management
ā¢ Stop the drug
ā¢ Symptomatic treatment
ā¢ Maintain nutrition & hydration
ā¢ Muscle relaxants
ā¢ Treat malignant hyperthermia
32. 12. Drug toxicity
ā¢ Drug overdose ā accidental or suicidal
ā¢ Find out the drug
ā¢ Collect detailed history
ā¢ Symptomatic treatment promptly
ā¢ Look for symptoms
Management
ā¢ Administer O2, start IV
ā¢ Assess for cardiac arrhythmias
ā¢ Refer for haemodialysis
ā¢ Administer anticonvulsants
33. 13. Victims of disaster
ā¢ People survived a sudden, unexpected, overwhelming stress
ā¢ E.g. earthquake, floods, riots, terrorism
ā¢ Evidenced by ā anger, frustration, guilt, numbness and
confusion
Management
ā¢ Treatment of life threatening physical problem
ā¢ Critical incident debriefing ā to reduce discomfort
ā¢ Group therapy
ā¢ Sedation
ā¢ Referral to psychiatrist
ā¢ Teach coping strategies
ā¢ Educate about the available services
34. 14. Rape Victim
ā¢ Rape ā an act of forceful sexual act with a female
against her will and consent
ā¢ Acute disorganization characterized by ā self
blame, fear of being killed, feeling of degradation,
loss of esteem, depersonalization, de-realization,
recurrent intrusive thoughts, anxiety & depression
Management
ā¢ Be supportive, reassuring & non-judgmental
ā¢ Physical examination for injuries
ā¢ Morning after pill to prevent pregnancy
ā¢ Investigation for HIV & STD
ā¢ Complications of PTSD, Vaginismus.
35. Summary
ā¢ Definition & meaning of Psychiatric
emergencies
ā¢ Types of psychiatric emergencies
ā¢ Etiology of psychiatric emergencies
ā¢ Management of different types of psychiatric
emergencies
36. References
ā¢ Niraj Ahuja, A short textbook of Psychiaty, Jaypee
Brothers ,Sixth edition.
ā¢ Louise Rebraca Shives, Basic concept of psychiatric ā
mental health nursing ,Lippincott Williams
&Wilkins,Seventh Edition.
ā¢ KP Neeraja, Essential of Mental Health &Psychiatric
Nursing, Jaypee Brothers Medical Publishers (p) LTD,
Volume 2.
ā¢ Katherine M. Fortinash, Psychiatric Nursing Care
Plans,Mosby, Fourth edition.