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Psychiatric Emergencies
   Patient’s behavior is disturbing to himself, his
    family, or his community
   Never assume patient has psychiatric illness
    until all possible physical causes are ruled out
   Causes
       Low blood sugar
       Hypoxia
       Inadequate cerebral blood flow
       Head trauma
       Drugs, alcohol
       Excessive heat, cold
       CNS infections
   Clues suggesting physical causes
       Sudden onset
       Visual, but not auditory, hallucinations
       Memory loss, impairment
       Altered pupil size, symmetry, reactivity
       Excessive salivation
       Incontinence
       Unusual breath odors
Anxiety
   Most common psychiatric illness (10% of adults)
   Painful uneasiness about impending problems,
    situations
   Characterized by agitation, restlessness
   Frequently misdiagnosed as other disorders
Anxiety
   Panic attack
       Intense fear, tension, restlessness
       Patient overwhelmed, cannot concentrate
       May also cause anxiety, agitation among
        family, bystanders
Anxiety
   Panic attack
         Dizziness                   Shortness of breath

      Tingling of fingers, area      Irregular heartbeat
      around mouth                    Palpitations
         Carpal-pedal spasms         Diarrhea
         Tremors                  Sensation of choking,
                                   smothering
Phobias
   Closely related to anxiety
   Stimulated by specific things, places, situations
   Signs, symptoms resemble panic attack
   Most common is agoraphobia (fear of open places)
Depression
    Deep feelings of sadness, worthlessness,
     discouragement
    Factor in 50% of suicides
Depression


Ask all depressed patients about suicidal thoughts


      Asking someone about suicide will NOT
           “put the idea in their head.”
Bipolar Disorder
   Manic-depressive
   Swings from one end of mood spectrum to other
   Manic phase: Inflated self-image, elation, feelings of
    being very powerful
   Depressed phase: Loss of interest, feelings of
    worthlessness, suicidal thoughts
   Delusions, hallucinations occur in either phase
Schizophrenia
   Debilitating distortions of speech, thought
   Bizarre hallucinations
   Social withdrawal
   Lack of emotional expressiveness
   NOT the same as multiple personality disorder
Delirium /dementia
   Consciousness
   Onset
   Last
   Orientation
   Memory
   Hallucinations
   Fluctuation
   EEG
Paranoia
   Exaggerated, unwarranted mistrust
   Often elaborate delusions of persecution
   Tend to carry grudges
   Cold, hypersensitive, defensive, argumentative
   Cannot accept fault
   Excitable, unpredictable
Catatonia
   Mutism
   Posturing
   Negativism
   Staring
   Rigidity
   echopraxia / echolalia
Suicide



Take ALL suicidal acts seriously!
Suicide
   Suicide attempt = Any willful act designed to end
    one’s own life
   10th leading cause of death in U.S.
   Second among college students
   Women attempt more often
   Men succeed more often
Suicide
   50% who succeed attempted previously
   75% gave clear warning of intent


         People who kill themselves, DO
            talk about it in advance!
Suicide
   Risk factors
       Men >40 y.o.
       Single, widowed, or divorced
       Drug, alcohol abuse history
       Severe depression
       Previous attempts, gestures
       Highly lethal plans
Suicide
   Risk factors
       Obtaining means of suicide (gun, pills, etc)
       Previous self-destructive behavior
       Current diagnosis of serious illness
       Recent loss of loved one
       Arrest, imprisonment, loss of job
Violence
Violence


   60 to 70% of behavioral emergency patients become
    assaultive or violent
Violence
   Causes include
       Real, perceived mismanagement
       Psychosis
       Alcohol, drugs
       Fear
       Panic
       Head injury
Violence to Others
   Warning signs
       Nervous pacing
       Shouting
       Threatening
       Cursing
       Throwing objects
       Clenched teeth and/or fists
Dealing with Psychiatric Emergencies
Basic Principles

   We all have limitations
   We have more coping ability than we think
   We all feel some disturbance when injured or
    involved in an extraordinary event
Basic Principles

   Emotional injury is as real as physical injury
   People who have been through a crisis do not
    just “get better”
   Cultural differences have special meaning in
    Psychiatric emergencies
Techniques

   Speak calmly, reassuringly, directly
   Maintain comfortable distance
   Seek patient’s cooperation
   Maintain eye contact
   No quick movements
Techniques

   Respond honestly
   Never threaten, challenge, belittle, argue
   Always tell the truth
   Involve trusted family, friends
Techniques

   Be prepared to spend time
   NEVER leave patient alone
   Avoid using restraints if possible
   Do NOT force patient to make decisions
Techniques


   Encourage patient to perform simple, non-
    competitive tasks
   Disperse crowds that have gathered
Assessment
   Pay careful attention to dispatch information
    for indications of potential violence
   Never enter potentially violent situations
    without police support
   If personal safety uncertain, stand by for police
   Quickly locate patient
   Stay between patient and door
   Scan quickly for dangerous articles
   If patient has weapon, ask him to put it down
   If he won’t, back out and wait for police
   In suicide cases, be alert for hazards
     Automobile running in closed garage
     Gas stove pilot lights blown out

     Electrical devices in water

     Toxins on or around patient
   Look for
       Signs of possible underlying medical problems
       Methods, means of committing suicide
       Multiple patients
Initial Assessment
  Identificationof life-threatening medical or
traumatic problems has priority over behavioral
                                      problem.
Focused History, Physical Exam
   Be polite, respectful
   Preserve patient’s dignity
   Use open-ended questions
   Encourage patient to talk; Show you are
    listening
   Acknowledge patient’s feelings
Assessment: Suicidal Patients
   Injuries, medical conditions related to attempt
    are primary concern
   Listen carefully
   Accept patient’s complaints, feelings
   Do NOT show disgust, horror
Assessment: Suicidal Patients
   Do NOT trust “rapid recoveries”
   Do something tangible for the patient
   Do NOT try to deny that the attempt occurred
   NEVER challenge patient to go ahead, do it
Assessment: Violent Patients
   Find out if patient has threatened/has history of
    violence, aggression, combativeness
   Assess body language for clues to potential violence
   Listen to clues to violence in patient’s speech
   Monitor movements, physical activity
   Be firm, clear
   Be prepared to restrain, but only if necessary
Management
   Your safety comes first
   Trauma, medical problems have priority
   Calm the patient; NEVER leave him alone
   Use restraints as needed to protect yourself, the
    patient, others
   Transport to facility with appropriate resources
Restraining Patients
   A patient may be restrained if you have good
    reason to believe he is a danger to:
       You
       Himself
       Other people
Restraining Patients
   Have sufficient manpower
   Have a plan; Know who will do what
   Use only as much force as needed
   When the time comes, act quickly; Take the
    patient by surprise
   At least four rescuers; One for each extremity
Restraining Patients
   Use humane restraints (soft leather, cloth) on
    limbs
   Secure patient to stretcher with straps at chest,
    waist, thighs
   If patient spits, cover face with surgical mask
   Once restraints are applied, NEVER remove
    them!
Reasonable Force
   Minimum amount of force needed to keep
    patient from injuring self, others
   Force must NEVER be punitive in nature
Medications/Drugs
   NMS
   Acute dystonia
   Serotonin syndrome
   Lithium toxicity
   W/D or intoxication
Psychiatric emergency

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Psychiatric emergency

  • 2. Patient’s behavior is disturbing to himself, his family, or his community
  • 3. Never assume patient has psychiatric illness until all possible physical causes are ruled out
  • 4. Causes  Low blood sugar  Hypoxia  Inadequate cerebral blood flow  Head trauma  Drugs, alcohol  Excessive heat, cold  CNS infections
  • 5. Clues suggesting physical causes  Sudden onset  Visual, but not auditory, hallucinations  Memory loss, impairment  Altered pupil size, symmetry, reactivity  Excessive salivation  Incontinence  Unusual breath odors
  • 6. Anxiety  Most common psychiatric illness (10% of adults)  Painful uneasiness about impending problems, situations  Characterized by agitation, restlessness  Frequently misdiagnosed as other disorders
  • 7. Anxiety  Panic attack  Intense fear, tension, restlessness  Patient overwhelmed, cannot concentrate  May also cause anxiety, agitation among family, bystanders
  • 8. Anxiety  Panic attack  Dizziness  Shortness of breath Tingling of fingers, area  Irregular heartbeat around mouth  Palpitations  Carpal-pedal spasms  Diarrhea  Tremors Sensation of choking, smothering
  • 9. Phobias  Closely related to anxiety  Stimulated by specific things, places, situations  Signs, symptoms resemble panic attack  Most common is agoraphobia (fear of open places)
  • 10. Depression  Deep feelings of sadness, worthlessness, discouragement  Factor in 50% of suicides
  • 11. Depression Ask all depressed patients about suicidal thoughts Asking someone about suicide will NOT “put the idea in their head.”
  • 12. Bipolar Disorder  Manic-depressive  Swings from one end of mood spectrum to other  Manic phase: Inflated self-image, elation, feelings of being very powerful  Depressed phase: Loss of interest, feelings of worthlessness, suicidal thoughts  Delusions, hallucinations occur in either phase
  • 13. Schizophrenia  Debilitating distortions of speech, thought  Bizarre hallucinations  Social withdrawal  Lack of emotional expressiveness  NOT the same as multiple personality disorder
  • 14. Delirium /dementia  Consciousness  Onset  Last  Orientation  Memory  Hallucinations  Fluctuation  EEG
  • 15. Paranoia  Exaggerated, unwarranted mistrust  Often elaborate delusions of persecution  Tend to carry grudges  Cold, hypersensitive, defensive, argumentative  Cannot accept fault  Excitable, unpredictable
  • 16. Catatonia  Mutism  Posturing  Negativism  Staring  Rigidity  echopraxia / echolalia
  • 17.
  • 18. Suicide Take ALL suicidal acts seriously!
  • 19. Suicide  Suicide attempt = Any willful act designed to end one’s own life  10th leading cause of death in U.S.  Second among college students  Women attempt more often  Men succeed more often
  • 20. Suicide  50% who succeed attempted previously  75% gave clear warning of intent People who kill themselves, DO talk about it in advance!
  • 21. Suicide  Risk factors  Men >40 y.o.  Single, widowed, or divorced  Drug, alcohol abuse history  Severe depression  Previous attempts, gestures  Highly lethal plans
  • 22. Suicide  Risk factors  Obtaining means of suicide (gun, pills, etc)  Previous self-destructive behavior  Current diagnosis of serious illness  Recent loss of loved one  Arrest, imprisonment, loss of job
  • 23.
  • 25. Violence  60 to 70% of behavioral emergency patients become assaultive or violent
  • 26.
  • 27. Violence  Causes include  Real, perceived mismanagement  Psychosis  Alcohol, drugs  Fear  Panic  Head injury
  • 28. Violence to Others  Warning signs  Nervous pacing  Shouting  Threatening  Cursing  Throwing objects  Clenched teeth and/or fists
  • 30. Basic Principles  We all have limitations  We have more coping ability than we think  We all feel some disturbance when injured or involved in an extraordinary event
  • 31. Basic Principles  Emotional injury is as real as physical injury  People who have been through a crisis do not just “get better”  Cultural differences have special meaning in Psychiatric emergencies
  • 32. Techniques  Speak calmly, reassuringly, directly  Maintain comfortable distance  Seek patient’s cooperation  Maintain eye contact  No quick movements
  • 33. Techniques  Respond honestly  Never threaten, challenge, belittle, argue  Always tell the truth  Involve trusted family, friends
  • 34. Techniques  Be prepared to spend time  NEVER leave patient alone  Avoid using restraints if possible  Do NOT force patient to make decisions
  • 35. Techniques  Encourage patient to perform simple, non- competitive tasks  Disperse crowds that have gathered
  • 37. Pay careful attention to dispatch information for indications of potential violence  Never enter potentially violent situations without police support  If personal safety uncertain, stand by for police
  • 38. Quickly locate patient  Stay between patient and door  Scan quickly for dangerous articles  If patient has weapon, ask him to put it down  If he won’t, back out and wait for police
  • 39. In suicide cases, be alert for hazards  Automobile running in closed garage  Gas stove pilot lights blown out  Electrical devices in water  Toxins on or around patient
  • 40. Look for  Signs of possible underlying medical problems  Methods, means of committing suicide  Multiple patients
  • 41. Initial Assessment Identificationof life-threatening medical or traumatic problems has priority over behavioral problem.
  • 42. Focused History, Physical Exam  Be polite, respectful  Preserve patient’s dignity  Use open-ended questions  Encourage patient to talk; Show you are listening  Acknowledge patient’s feelings
  • 43. Assessment: Suicidal Patients  Injuries, medical conditions related to attempt are primary concern  Listen carefully  Accept patient’s complaints, feelings  Do NOT show disgust, horror
  • 44. Assessment: Suicidal Patients  Do NOT trust “rapid recoveries”  Do something tangible for the patient  Do NOT try to deny that the attempt occurred  NEVER challenge patient to go ahead, do it
  • 45. Assessment: Violent Patients  Find out if patient has threatened/has history of violence, aggression, combativeness  Assess body language for clues to potential violence  Listen to clues to violence in patient’s speech  Monitor movements, physical activity  Be firm, clear  Be prepared to restrain, but only if necessary
  • 46. Management  Your safety comes first  Trauma, medical problems have priority  Calm the patient; NEVER leave him alone  Use restraints as needed to protect yourself, the patient, others  Transport to facility with appropriate resources
  • 47. Restraining Patients  A patient may be restrained if you have good reason to believe he is a danger to:  You  Himself  Other people
  • 48. Restraining Patients  Have sufficient manpower  Have a plan; Know who will do what  Use only as much force as needed  When the time comes, act quickly; Take the patient by surprise  At least four rescuers; One for each extremity
  • 49. Restraining Patients  Use humane restraints (soft leather, cloth) on limbs  Secure patient to stretcher with straps at chest, waist, thighs  If patient spits, cover face with surgical mask  Once restraints are applied, NEVER remove them!
  • 50. Reasonable Force  Minimum amount of force needed to keep patient from injuring self, others  Force must NEVER be punitive in nature
  • 51. Medications/Drugs  NMS  Acute dystonia  Serotonin syndrome  Lithium toxicity  W/D or intoxication