Psychiatric Emergencies

Paul Scavella
University of the West Indies
Psychiatry Clerkship
18/03/2016

Definitions
Emergency

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 contd
Psychiatric

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.

Characteristics
Any

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

intervention
Safeguard

the life of the patient

Reduce anxiety of family
Enhance 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 Emergencies
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
1.

General guidelines of management

for Psychiatric Emergencies
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
4.

Epidemiology
In 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.

Prevalence
Rate

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 settings
Most

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.

Evaluation
Primary

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

Evaluation
The

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.

Evaluation
The

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 Psychiatric
Conditions

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 disorder
Acute

onset (within hours or minutes,

with prevailing)
First episode
Geriatric age
Current medical illness or injury
Significant substance abuse
Non-auditory disturbances of perception
Neurological symptoms LOC, seizures,
head injury, change in headache
pattern, change in vision

Specific Interview
Situations
Psychosis

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 risk
Previous

attempt or fantasized suicide

Anxiety, depression, exhaustion
Availability of means of suicide
Concern for effect of suicide on family
members
Verbalised suicidal ideation
Preparation of will, resignation after agitated
depression
Proximal life crisis, such as mourning or
impending surgery
Family History of suicide
Pervasive pessimism or hopelessness

Treatment goals

Treatment of Emergencies
Psychotherapy

In an emergency psychiatric
intervention, all attempts are made
to help patients 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 Emergencies
Pharmacotherapy

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 Emergencies
Restraints

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 patients 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. IVs 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
Emergencies
Disposition

In some cases admitting or

discharging the patient is not
optimal
Some conditions have to be
managed in an extendedobservation setting, e.g., adjustment
reaction to a traumatic event
Best to admit patient voluntarily,
however very difficult to

Suicide
One

of the commonest
psychiatric emergencies
Commonest cause of death
among psychiatric patients
Defined as the intentional taking
of ones life in a culturally nonendorsed manner

Suicide
Aetiology

Psychotic Disorder

1.

2.

3.

Major Depression
Schizophrenia
Substance abuse
Dementia
Delirium
Personality disorder

Physical Disorder
Chronic or incurable physical disorders like Cancer, AIDS

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

Suicide
Risk

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

Management
Be

aware of the warning signs

Monitor the patients safety
needs
Acute psychiatric interview
Counseling & Guidance
Deal with ongoing life stressors and
teach new coping skills
Treatment

disorders

of psychiatric

Violence/Excitement/Aggressive
Behaviour
Physical

aggression by one
person on another
During this stage patient will be
irrational, uncooperative,
delusional and assaultive

Violence/Excitement/Aggressive
Behaviour: Aetiology
Organic

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: Management
Reassurane
Sedation

if necessary

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

detailed history and explore cause

Complete physical exam
Provide care and do due diligence
Physical restraints last resort

Stupor & Catatonic

Syndrome
Clinical

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:

Management
Ensure

patient airway
Maintain hydration
History and PE
Ancillary investigations before
starting treatment
Provide care for unconscious
patient
Skin, nutrition, elimination, personal
hygiene

Panic Attacks
Episodes

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:
Management
Give

reassurance
Find cause
Injection of Diazepam 10mg or
lorazepam 2 mg in acute setting
Counsel patient and relatives
Cognitive Behavioural therapy

Victims of Disaster
People

who have survived a

sudden, unexpected,
overwhelming stress
Features
Anger, Frustration, Guilts
Numbness, Confusion
Flashbacks, Depression

Victims of Disaster: Management

Treatment

of the life-threatening
physical problem
Intervention
Listen attentively, dont interrupt
Acknowledge understaning of the pain and
distress
Console if appropriate (pat on the shoulder)
Dont ask them to stop crying
Group

therapy
Benzodiazepines can be given to reduce
anxiety

Hysterical Attacks
A

hysteric may mimic

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

Hysterical attacks:
Management
Help

patient realise the meaning

of the symptoms and help them
find alternative ways of coping
with stress
IV pentothal is useful
Relieve anxiety amonth family
members

Delirium Tremens
Life

threatening alcohol
withdrawal syndrome peaks a
days 2 to 5 after last drink
Characterised by delirium,
hyperthermia, tachycardia,
seizures

TIME
6 to

8 hours

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)

ALCOHOL WITHDRAWAL
TIMELINE

Delirium Tremens:
Management
Best

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 Furor
Following

an epileptic attach
patient may behave strangely
and become excited or violent
Management
Diazepam 10 mg IV
Haloperidol 10 mg IV

Drug Adverse Effects

Neuroleptic

Malignant Syndrome
AE of Antipsychotics

FEVER mnemonic
Fever
Encephalopathy
Elevated Enzyme (CK) and WBCs
Rigidity

Drug Adverse Effects

NMS

Management

Stop the causative drug

Cool the patients body temp
Maintain fluid and electrolyte blance
Dantrolene

Drug Adverse Effects

Serotonin 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,
Mental
Muscle

Diarrhea ,Heavy sweating not due to activity Fever

status changes such as confusion or hypomania

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
In

of medicines that caused the syndrome

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
In

of medicines that caused the syndrome

life-threatening cases, paralytics and intubation may

be necessary to avoid further damage.