Psychiatric emergencies in mental health.

1. Psychiatric Emergencies(Part 1)
Dr. Bilal Ahmed(PGY-III)

2. 35 year old female, with NKCM brought to the
COVID ward, unresponsive and mute, legs and arms
in weird posture, staring at the ceiling.
On examination, limbs were rigid and moving back
into the same posture after force was removed. It
seemed that she was actively resisting my efforts with
equal force. Upon calling her name and shaking her,
she would just stare at me blankly, not verbalizing at
all.
I clerked her, started her on some medications and
spoke to her family. I found out that she was on some
psychotropics, had recently had a fight with her
daughter and had been under stress. I was confused.
Later, the nurse alarmingly called me saying the
patient became responsive and slapped her! This
happened after she had given her IM
Midazolam(BZD).

3. A behavioral syndrome marked by an inability to move normally despite full physical capacity to do so. The
syndrome occurs in the context of many psychiatric and general medical disorders.
The syndrome is marked by heterogeneous signs that are observed or elicited; the most common are immobility,
rigidity, mutism, posturing, excessive motor activity, stupor, negativism, staring and echolalia.
Associated with:
Psychiatric illnesses: Mood disorders(BAD, MDD) > Psychotic disorders
General medical conditions: Delirium, metabolic disturbances,heat stroke, autoimmune and endocrine illnesses
Neurological conditions: seizures, strokes, Parkinson’s, post-encephalitic states
Neurobiology:
↓ activity at gamma-aminobutyric acid A and dopamine D2 receptors
↑ activity at N-methyl-D-aspartate receptors
-At the level of Basal Ganglia and hypothalamus
Catatonia

4. Types
● Stuporous
● Excited
● Malignant

7. 45 year old male with history of whisky
and beer drinking for the last 20 years,
had been convinced by his sisters, who
were visiting from the US, to quit his
alcohol use due to derangements in his
LFTs.
Patient was admitted to the psych ward
and started on Lorazepam 2 mg Q4H. 3
days into his admission, he began to have
tachycardia, raised BP, disorientation to
time and developed irrelevant talking.
IM was taken on board and the patient
was shifted to the special care unit for
further management.

8. Delirium Tremens
● 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. It is a life
threatening condition requiring immediate medical management.
Risk factors:
H/O alcohol withdrawal seizures, h/o DTs, presence of concurrent illness, low K, low Mg, thiamine deficiency,
>30 years of age, severe alcohol withdrawals

9. Management
● Patient will need HDU/ICU care with joint work between medical, nursing and
psychiatric teams.
● Excluding alternative diagnoses(!!!)
● Correction of contributing physical factors such as electrolyte imbalance(K,
Mg),thiamine deficiency, fluid status and sepsis.
● Minimizing behavioural disturbance via psychosocial measures (side room for a low
stimulus environment, 1:1 nursing observations, frequent reorientation and
reassurance) and pharmacological treatment.

10. ● IV Thiamine(Neurobion) 1 amp TID
● High dose Parenteral/enteral benzodiazepines(Diazepam/Lorazepam) are used to
control psychomotor agitation and prevent progression to more severe withdrawal.
● AVOID antipsychotics! Only use if BZDs fail.

11. Acutely disturbed or violent behavior
Can occur in the context of psychiatric illness, physical illness, substance use or personality
disorders.
-Ensure your safety first
-Assess the situation and patient’s mental status and try to negotiate with the patient.
-Verbal de-escalation techniques→offer food, a chair, be mindful of tone, eye contact;
verbal/non verbal cues. Be firm but receptive and non confrontational.
-Limit setting and maintaining boundaries. At times, patients may need to be secluded or a
‘time out’ should be done.

13. Research has also shown combination therapy(Antipsychotic+BZDs) to be better than just using one drug class for tranquilization:
Midazolam (5 mg IV or IM) and droperidol (5 mg IV or IM)
Lorazepam (2 mg IV or IM) and haloperidol (5 mg IV or IM)
These combinations achieve more rapid sedation than either drug alone and may reduce side effects.
Be mindful of the built and age of patients when deciding the dose.
→Vital monitoring post parenteral administration

14. ER: PHQ-2 and PHQ-9 are used
Policies for Suicidal patients

19. Seizures