Psychiatric Emergencies

Yetnayet Bekele
Msc in ICMMH and Msc in leadership
Introduction
This course introduces
• students the issue of psychiatric emergencies.
• Psychiatric illnesses that may require emergency treatment are divided
between those involving adults and children.
• individual illnesses are presented with a short description of the presenting
symptoms and possible areas of differential diagnosis before treatment is
started.
• Common treatment approaches are provided for each psychiatric illness
described.
• introduced to potential dangers and ways to minimize the possibility of
injury to either medical personnel or the patient.
Course Objective

 The purpose of this course is to help students recognize psychiatric

emergencies, identify common psychiatric illnesses that may share
symptoms with physical illness, and improve the management of
psychiatric emergencies.
Learning Objectives

Upon completion of this course, you should be able

to:
 Outline the history and appropriate use of the emergency department (ED).
 Cite statistics regarding ED utilization.
 Describe the medical evaluation of psychiatric patients in the emergency setting.
 Discuss components of a psychiatric assessment in the ED.
 Review common medical conditions that may be linked to psychiatric issues.
 Define imminent danger.
 Identify common psychiatric conditions that may precipitate emergencies in adults.
 Recognize psychiatric illnesses in children and adolescents that may necessitate
emergency intervention.
 Describe the appropriate management of psychiatric emergencies, including the
necessity for providing information in the patient's native language.
 Outline appropriate discharge planning for patients who have been treated for
psychiatric emergencies.
 List interventions that should be utilized in the case of a psychiatric emergency
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 cont’d
 A psychiatric emergency has been defined as, "any behavior that
cannot be dealt with as rapidly as needed by the ordinary mental
health, social service, or criminal justice system in a community"
 the American Psychiatric Association (APA) has indicated that a
psychiatric emergency is "an acute disturbance of thought,
behavior, or social relationship that requires an immediate
intervention as defined by the patient, the family, or the
community"
 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
PSYCHIATRIC ASSESSMENT
 A full psychiatric assessment is complex, the details of which are
beyond the scope of this course.
 Assess and enhance the safety of the patient and others.
 Establish a provisional diagnosis (or diagnoses) of the mental
disorder(s) most likely to be responsible for the current emergency.
 Identify family or other involved persons who can provide
information that will help determine the accuracy of reported
history.
 Identify any current treatment providers who can provide
information relevant to the evaluation.

 Identify social, environmental, and cultural factors relevant to

immediate treatment decisions.
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
 Suicideor deliberate self harm
 Violence/Excitement/agression
 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

1. 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
Emergencies

4. 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
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, 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 Laboratory 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 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 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 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 Emergencies
Disposition
◦ 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
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 non-endorsed manner
Suicide
 Aetiology
1. 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
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
 Beaware of the warning signs
 Monitor the patient’s safety needs
 Acute psychiatric interview
 Counseling & Guidance
◦ Deal with ongoing life stressors and teach new coping skills
 Treatment of psychiatric disorders
Violence/Excitement/Aggressive Behaviour

Physical aggression by one person on

another
During this stage patient will be
irrational, uncooperative, delusional and
assaultive
What is Assertion, Agression and
Violence
 Assertion is a generic term for all behavior, with or
without hostile intent, which is designed to gratify a
need.
 Aggression is a specific form of assertion that has
hostile intent.
 Violence pertains to the use of physical force and is the
exertion of physical force so as to injure or abuse.
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
Risk factors
• A history of violence
• Age (younger, majority age 20-40)
• Gender (males more than females)
• Alcohol/drugs
(dependence/intoxication/withdrawal)
• Socioeconomic status (low more than high)
• Estimated IQ (low more than high)
• Residential mobility
• Marital status (lack of)
Triggers can include:
 intoxication
 loss of a central love relationship
acute emotional crisis
loss of personal power
fear
 pain
physiological states, e.g. hunger, thirst, lack of sleep
staff reactions
 rejection
disrespect, etc.
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
 Collectdetailed history and explore cause
 Complete physical exam
 Provide care and do due diligence
 Physical restraints – last resort
Mechanism Con...
Mechanism Cont..
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, 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 therapy
Benzodiazepines can be given to reduce
anxiety
Hysterical Attacks
A hystericmay 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 amoung family members
Delirium Tremens
Delirium Tremens defenation

 Delirium tremens (DT) is a severe form of alcohol

withdrawal syndrome that occurs in individuals who
have been drinking heavily for a prolonged period of
time and then suddenly stop or significantly reduce
their alcohol intake

 Life threatening alcohol withdrawal syndrome –

peaks a days 2 to 5 after last drink
 Characterised by delirium, hyperthermia, tachycardia,
seizures
Delirium Tremens (DT)
DT is defined by hallucinations,
disorientation, tachycardia, hypertension,
hyperthermia, agitation, and diaphoresis in
the setting of acute reduction or abstinence
from alcohol.
DT typically begins between 48 and 96 hours
after the last drink and lasts one to five days.
Virtually all patients who develop DT
experience some symptoms of minor alcohol
withdrawal prior to the onset of DT.
TIME SYMPTOMS

6 to 8 hours TREMULOUSNESS (shakes

or jitters)
8 to 12 hours Psychotic and perceptual
symptoms
 12 Seizures
to 24 hours

 During Delirium Tremens (DTs)

72 hours but can be
up to one week.

ALCOHOL WITHDRAWAL
TIMELINE
 MANAGEMENT

Excluding alternative diagnoses:

A premature diagnosis of alcohol withdrawal can lead to inappropriate use of
sedatives, which can further delay accurate diagnosis
Symptom control and supportive care:Once comorbid illnesses have been
excluded or adequately treated, the management of alcohol withdrawal is directed
at alleviating symptoms and identifying and correcting metabolic derangements.
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.
Status Epileptic
Cont....
Management of Status Epileptics
Dystonic Reaction due to Psychotropic
Drugs:
 This is an acute adverse extra pyramidal effect to use of anti-psychotic
drugs like haloperidol and chlorpromazine
 Dystonic reactions are characterized by intermittent spasmodic or sustained
involuntary contractions of muscles in the face, neck, trunk, pelvis, and
extremities.
 Management includes taking relevant history to confirm prior anti-
psychotic drug intake or overdose and brief examination.
 Give either injection diazepam 10 mg IV stat slowly
 oral trihexyphenidyl tablet 2 mg t.i.d.
 revise anti-psychotic drug regimen.
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, 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

 Inlife-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

 Inlife-threatening cases, paralytics and intubation may be

necessary to avoid further damage.
case 2