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PSYCHIATRIC EMERGENCIES Prof J.B.ASARE CONSULTANT PSYCHIATRIST Emergency psychiatry identifies and treats emergencies related to mental diseases, social problems resulting in sudden behavioral change and mental disturbances associated with some types of physical illness EMERGENCIES IN PSYCHIATRY Attempted suicide/parasuicide Severe Depression with suicidal ideas Substance abuse/intoxication and withdrawal states Delirium tremens Violent Behavior Hazardous drug reaction Neuroleptic Malignant Syndrome Status Epilepticus Types of Emergencies - Mode : cutting the wrists, overdose of drugs, using toxic substances like rat killers, herbicides corrosive substances. Gender- more girls than boys in the teenage period but more men than women in those above the age of 50years Risk of suicide 1% and higher in men than women and increases with age.It is about 7 times higher in those above 55years at the time of self harm Attempted suicide - - Causes Call for help Attention seeking behaviour? For secondary gain Psychotic behaviour Depression/Emotional problems Stress Crisis situation Attempted Suicide Risk factors: Family conflict Abuse and neglect Life events such as loss and trauma Relationship difficulties Feeling rejected Temperament Personality Depression Eating disorders Young people who use drugs and alcohol Attempted suicide Risk factors for suicide: Young men Mental health difficulties Personality difficulties Stressful events Young people who regularly self harm Drug and alcohol use Attempted suicide Within a protected environment, psychiatric emergency services exist to provide brief stay of two or three days to gain a diagnostic clarity and provide first aid Treat those patients whose symptoms can be improved within that brief period of time. Find appropriate alternatives to psychiatric hospitalization for the patient. Management Assessment –psychiatric history; Physical assessment and evaluation of health status Assessment of danger and provision of security Social and psychological evaluation(if necessary) Arranging for social support Counseling and treatment of underlying psychopathology Management Pt has clinical symptoms of severe depression (e.g. Wt loss, poor appetite, insomnia, social withdrawal, negative thoughts etc) Suicidal ideas are paramount Has limited social support Not being treated for depression There may be a long standing social problem with a state of helplessness Severe Depression Refer or admit if specialist facility is available Arrange for social enquiry and support Detail somebody to supervise Remove offensive materials/equipment that can be used for suicide e.g. drugs, chemicals , sponge, belt, rope, tie etc Sedate and use antidepressants. Counselling Consider ECT Intervention Substances such as Heroin, Pethidine and codeine produce intoxication when taken in heavy doses (”bad trip’) This will manifest as delirium with accompanying behavioral problems. Some cannabis and cocaine abusers can present with acute psychotic behaviours manifesting as violent and aggressive behaviours. Substance Abuse intoxication and withdrawal Assessment – Psychiatric and physical Admit Apply intra muscular injection of nueroleptics or intravenous sedation using Diazepam Organize social, psychological and psychiatric interventions through referral Management Acute Alcohol withdrawal in alcoholics who had abstained from alcohol from 2472hours or those who did not have enough alcohol to drink during a bout. They manifest with Coarse tremors, sweating, restlessness, visual hallucinations and some level of aggressiveness and confusion Delirium Tremens A medical emergency Check vitals Provide infusions Iv Diazepam 10 -20mg Iv Parenterovite 1 & 2 or thiamine 50-100mg - May require inj im 50mg of chlorpromazine to settle if liver is ok - Anticonvulsants may be necessary if seizures are present - Observe - Management - Continue with sliding doses of Diazepam and tab thiamine e.g. 1st day diazepam 10mg qds 2nd day ‘ ‘’ 10mg tds. 3rd day ‘’ ‘’ 10mg bd 4th day ‘’ ‘’ 10mg daily 5th day ‘’ ‘’ 5mg daily - continue with vitamins and refer to AA(Alcoholic Anonymous) Counseling and Rehabilitation Management Aggression can be the result of both internal and external factors that create a measurable activation in the autonomic nervous system . This activation can become evident through symptoms such as the clenching of fists or jaw, pacing, slamming doors, hitting palms of hands with fists, or being easily startled Violence is also associated with many conditions such as, acute psychosis, acute alcohol intoxication ,Paranoid personality disorder, antisocial personality disorder etc Violent Behaviors Risk factors may include :- Previous history of arrests - presence of hallucinations - delusions, - Handicapped in reasoning, - Use of psychoactive substances etc Violent Behaviour Assessment of the person and local security Mobilize more hands for support Assess eye to eye contact and readiness to respond to suggestions Attempt Physical examination and quick MSE Consider chemical restraint if cooperation is not being assured and the person is a risk to him/herself or others Management of aggressive patient iv Diazepam 20mg for an adult in bolus dosage Precautions should be taken if the patient has respiratory problems. Inject im. chlorpromazine 100-200mg st. Ensure that the BP is not below 100 mm Hg systolic Admit and observe Rapid Tranquillization Laboratory investigation Exclude space occupying lesion. Give medication to control aggression, mood and psychotic symptoms if available Psychotropic medication, mood stabilizers such as Sodium valporate, Carbamazepine can be used. Management of violent person Clinical implications When a person suffering from Schizophrenia or another psychotic illness Is violent, delusions are likely to be a major factor in causing the offence Alcohol and illicit substance misuse has probably become more prevalent among people with serious mental disorder manifesting with violent behaviour and targeted attention should be given to them Violent Behaviour Dangerous reactions from psychiatric medications, especially antipsychotics, are considered psychiatric emergencies. E.g. Ocurogyric crisis, Dystonic reaction Tremors and restlessness. Protruding of the tongue Excessive salivation Hazardous Drug Reactions - Causes Blockade of the dopamine receptor D1 implicated leading to abnormal functions of the basal ganglia. The use of antipsychotic drugs like haloperidol and chlorpromazine common People using dopaminergic drugs such as levodopa for Parkinson’s disease Even some drugs without known anti – dopaminergic activity such as lithium,desipramine,dothiepin,phenelzine etc have been associated with NMS Neuroleptic Malignant syndrome Neuroleptic malignant syndrome is a potentially lethal complication of first or second generation antipsychotics. If untreated, neuroleptic malignant syndrome can result in fever, muscle rigidity, confusion, unstable vital signs, or even death. Stop the Neuroleptic Give infusions Treat hyperthermia aggressively such as using cool blankets and ice packs to the axillae and groin Supportive care in intensive unit may be desirable Benzodiazepines may be used to reduce agitation Management of NMS Symptoms - Muscle cramps, tremors and fever - Symptoms of autonomic nervous system instability such as unstable blood pressure - Alterations in mental state such as agitation, delirium and coma Neuroleptic Malignant Syndrome Reassure client Administer Anti cholinergic medication e.g. Iv Benztropine 2mg If not available, tab. benztropine 2mg bd or tab. Benzhexol In very severe cases, injection Diazepam between 5-10mg could be given and the patient detained for a few hours. Management of drug reactions Frequent continuous seizures which can lead to brain irreversible damage. Children and the aged are vulnerable It becomes a medical/Psychiatric emergency because sufferers can lose their lives in the process of frequent seizures through asphyxia Status Epilepticus In iv Diazepam 10 -20mg can be given cautiously Or Iv Phenytoin 100mg Then continue with anticonvulsants Counseling Management of status epilepticus Crisis Intervention can be defined as emergency psychological care aimed at assisting individuals in a crisis situation to restore equilibrium to their biopsychosocial functioning and to minimize the potential for psychological trauma Crisis Intervention Crisis can be defined as one’s perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms Crisis Intervention Personal trauma and Societal or mass trauma Personal Trauma is defined as an individual’s experience of a situation or event in which he/she perceives to have exhausted his/her coping skill, self-esteem, social support and power. These can be situations where a person is making suicidal threats, experiencing threat, witnessing homicide or suicide, or experiencing personal loss. Types of crisis Societal or mass trauma can occur in a number of settings and typically affect a large group or society. These are instances such as school shootings, terrorist attacks, and natural disaster. Types of crisis On the cognitive level they may blame themselves or others for the trauma. Oftentimes the person appears disoriented, becomes hypersensitive or confused, Has poor concentration, uncertainty, Physical responses to trauma include: increased heart rate, tremors, dizziness, weakness, chills, headaches, vomiting, shock, fainting, sweating, and fatigue Typical Responses to crisis Emotional responses consist of apathy, depression, irritability, anxiety, panic helplessness, hopelessness, anger, fear, guilt, and denial. When assessing behavior some typical responses to crisis are difficulty in eating and/or sleeping, conflicts with others, withdrawal from social situations, and lack of interest in social activities. Responses to crisis Intervene as quickly as possible. Assess the needs of the person or survivors if it is mass trauma Resource mobilization should be immediately embarked upon in order to provide victims with the tools they need to return to some sort of order and normalcy, In addition they are to be helped to function independently. The next step is to facilitate understanding of the event by processing the situation or trauma Referrals to be made after assessment to specialized areas Intervention