Sections Behavioral Emergencies Pathophysiology of Psychiatric Disorders Assessment of Behavioral Emergency Patients Specific Psychiatric Disorders Management of Behavioral Emergencies Violent Patients and Restraint
Behavioral Emergencies Behavior Normal versus Abnormal Behavior Indications of a Behavioral or Psychiatric Condition Behavior that interferes with core life functions Behavior that poses a threat to the life or well-being of the patient or others Behavior that deviates significantly from society’s expectations or norms
Pathophysiology of Psychiatric Disorders Mental Health Problems Role of Medication Noncompliance Causes of Disorders Biological (Organic) Cause related to disease process or structural changes Psychosocial Cause related to the patient’s personality style, unresolved conflicts, or crisis management methods Sociocultural Cause related to the patient’s actions and interactions with society
Assessment of Behavioral Emergency Patients Scene Size-up Ensure Personal Safety Initial Assessment Suspect Life-Threatening Emergencies Assess and Manage ABCs General Impression Consider posturing, hand gestures, and signs of aggression. Observe the patient’s awareness, orientation, cognitive abilities, and affect. Consider the patient’s emotional state. Control the Scene
Assessment of Behavioral Emergency Patients Focused History and Physical Exam Obtain the Patient’s History Listen. Spend time. Be assured. Do not threaten. Do not fear silence. Place yourself at the patient’s level. Keep a safe and proper distance. Appear comfortable. Avoid appearing judgmental. Never lie to the patient.
Assessment of Behavioral Emergency Patients Mental Status Examination General Appearance Mood and Affect Behavioral Intelligence Observations Thought Processes Orientation Insight Memory Judgment Sensorium Perceptual Psychomotor Processes
Assessment of Behavioral Emergency Patients Psychiatric Medications Determine Presence and Type Compliance Identify Mental Health Professional
Specific Psychiatric Disorders Cognitive Disorders Delirium Rapid onset of widespread, disorganized thought Dementia Gradual development of memory impairment and cognitive disturbances • Aphasia, apraxia, agnosia, disturbance in executive functioning
Specific Psychiatric Disorders Anxiety and Related Disorders Panic Attack Differentiating the panic attack from medical conditions Four symptoms peaking within 10 minutes • Palpitatations, sweating, trembling or shaking, shortness of breath or smothering, feelings of choking, chest pain or discomfort, nausea, abdominal distress, paresthesias, chill, hot flashes, derealization or depersonalization, dizziness, unsteadiness, or lightheadedness • Fear of losing control, going crazy, or dying
Specific Psychiatric Disorders Phobias Excessive fear that interferes with functioning Posttraumatic Stress Syndrome Reaction to an extreme, life-threatening stressor Characteristics • Recurrent, intrusive thoughts • Sleep disorders and nightmares • Survivor’s guilt • Often complicated by substance abuse
Specific Psychiatric Disorders Mood Disorders Depression Major Depressive Episodes • Depressed mood lasting all day, nearly every day • Diminished interest in pleasure and daily activities • Significant weight change • Insomnia or hypersomnia • Psychomotor agitation or retardation • Feelings of worthlessness or excessive guilt • Diminished ability to think; indecisiveness • Recurrent thoughts of death
Specific Psychiatric Disorders Major Depressive Disorder • Requires 5 or more symptoms present during the same 14 day period. • Depression cannot be accounted for by other problems. • In Interest S Sleep A Appetite D Depressed Mood C Concentration A Activity G Guilt E Energy S Suicide
Specific Psychiatric Disorders Bipolar Disorder Manic episodes • Inflated self-esteem or grandiosity • Decreased need for sleep • More talkative than usual or pressure to keep talking • Flight of ideas or subjective experience that thoughts are racing • Distractibility • Increase in goal-directed activity • Excessive involvement in pleasurable activities • Delusional thoughts May alternate with depressed episodes. Lithium is used.
Specific Psychiatric Disorders Substance-Related Disorders Physiological and Psychological Dependence Somatoform Disorders Symptoms without Cause Somatization disorder Conversion disorder Hypochondriasis Body dysmorphic disorder Pain disorder
Specific Psychiatric Disorders Factitious Disorders Characteristics Intentional production of physical or psychological signs or symptoms Motivation for the behavior is to assume the “sick” role External incentives for the behavior • Avoiding police or work
Specific Psychiatric Disorders Suicide Assessing Potentially Suicidal Patients Document observations about the scene that may be valuable to mental health professionals. Document any notes, plans, or statements made by the patient. Treat traumatic or medical complaints.
Suicide Risk Factors Previous attempts Major separation Depression trauma Age Major physical 15–24 or over 40 stresses Alcohol or drug abuse Loss of independence Divorced or widowed Lack of goals and Giving away plan for the future belongings Suicide of same- Living alone or in sexed parent isolation Expression of a plan Presence of psychosis with depression for suicide Homosexuality Possession of the HIV status mechanism for suicide
Specific Psychiatric Disorders Crisis in the Geriatric Patient Assess the patient’s ability to communicate. Provide continual reassurance. Compensate for the patient’s loss of sight and hearing with reassuring physical contact. Treat the patient with respect. Avoid administering medication. Describe what you are going to do before you do it. Take your time. Allow family and friends to remain with the patient whenever possible.
Specific Psychiatric Disorders Crisis in Pediatric Patients Avoid separating young children from their parent. Prevent children from seeing things that will increase their distress. Make all explanations brief and simple. Be calm and speak slowly. Identify yourself. Be truthful with children. Encourage children to help with their care.
Specific Psychiatric Disorders Reassure children by carrying out all interventions gently. Do not discourage children from crying or showing emotions. If you will be separated from children, introduce the next person who will assume their care. Allow children to keep a favorite blanket or toy. Do not leave children alone.
Management of Behavioral Emergencies General Management Ensure scene safety and BSI precautions. Provide a supportive and calm environment. Treat any existing medical conditions. Do not allow the suicidal patient to be alone. Do not confront or argue with the patient. Provide realistic reassurance. Respond to the patient in a simple, direct manner. Transport to an appropriate receiving facility.
Management of Behavioral Emergencies Medical Treat Underlying Problems. Psychological Build Trust. Use interviewing Skills. “Talk Down” the Patient.
Violent Patients and Restraint Violent Patients EMS Safety Laws of Consent Authority to determine competence Determining Threat Threat to self Threat to others
Violent Patients and Restraint Methods of Restraint Guidelines Use the minimum force needed. Use appropriate devices to perform restraint. Restraint is not punitive. Patients who have been restrained require careful monitoring. Materials for Restraint
Restraining the Unarmed Patient Ensure you have adequate assistance and prepare the stretcher and restraints. Encircle the patient and give him or her one last opportunity to cooperate.
Restraining the Unarmed Patient Assign one person to each limb and approach at the same time. Keep communicating with the patient.
Restraining the Unarmed Patient Once patient is restrained, move patient to a prone or laterally recumbent position on the stretcher and secure. Keep the patient restrained throughout transport.
Positioning and Restraining Patients for Transport Positioning the patient prone reduces resistance and allows continued airway maintenance. Keep the stretcher in its lowest position.
Positioning and Restraining Patients for Transport Continually reassess the patient’s airway, breathing, and circulation. Be alert for signs of positional asphyxia. Never hog-tie or use hobble restraints. Chemical restraint
Psychiatric and Behavioral Disorders Behavioral Emergencies Pathophysiology of Psychiatric Disorders Assessment of Behavioral Emergency Patients Specific Psychiatric Disorders Management of Behavioral Emergencies Violent Patients and Restraint