psychiatric emergencies and its management

3. ☻Psychiatric emergency is a condition wherein
the patient has disturbances of thought, affect
and psychomotor activity leading to a threat
to his existence (suicide), or threat to the
people in the environment (homicide).
☻This condition needs immediate
intervention to safeguard the life of
the patient, bring down the anxiety
of the family members and
enhance emotional security to
others in the environment.

5. A psychiatric emergency is a
disturbance in thoughts, feeling
or actions that requires
immediate treatment.
(Kaplan and Sadock)

7. ¶Any condition/ situation making the patient &
relatives to seek immediate treatment.
¶Disharmony between subject and environment
¶Sudden disorganization in personality which
affects the socio-occupational functioning.

9. ⁂To enhance emotional security of others in the
environment.
⁂To bring down the anxiety of family members.
⁂To safeguard the life of patient.

10. TYPES OF
PSYCHIATRIC
EMERGENCIES

11. ⁕Suicide or deliberate self harm
⁕Violence or excitement
⁕Stupor.
⁕Panic
⁕Withdrawal symptoms of drug dependence.
⁕Alcohol or drug over dose.
⁕Delirium
⁕Epilepsy or status epileptics
⁕Severe depression (suicidal or homicidal
tendencies, agitation or stupor)
⁕Iatrogenic emergencies

12. Side effects of psychotropic drugs
Extra pyramidal syndrome
Dystonia
Akathisia
Mania due to antidepressants
Lithium toxicity
Psychiatric complications of drugs used in
medicine ( eg: INH, steroids, etc.)
⁕Abnormal responses to stressful
situations.(dangerousness of the patient’s behavior)
⁕Others(acute psychiatric condition, battered baby
syndrome, ICU syndrome)

13. SUICIDE
(DELIBERATE SELF HARM)

14. One of the commonest psychiatric emergency.
Commonest cause of death among psychiatric
patients.
Attempted suicide is an unsuccessful suicidal
act with a nonfatal outcome.

15. EPIDEMIOLOGY

16. One among the top 10 causes of death
Suicide rate in India – 10.8 per 1 lakh population
Male to female ratio – 64 : 36
Highest in the age group 15-29 yrs
Methods used
jumping in front of train or vehicle (3%)
Drowning (6.7%)
Burning (8.8%)
Hanging (32.2%)
Ingestion of poison (34.8%)

17. DEFINITION
Suicide is defined as the intentional taking
of one’s life in a culturally non-endorsed
manner.

18. ETIOLOGY
Psychiatric disorders
‽Major depression
‽Schizophrenia
‽Drug or alcohol abuse
‽Dementia
‽Delirium
‽Personality disorder

19.  Physical disorders
•Chronic or incurable physical disorders like
cancer, AIDS
Psychosocial factors
•Failure in examination
•Dowry harassment
•Marital problems
•Loss of loved object
•Isolation and alienation from social groups
•Financial and occupational difficulties

20. RISK FACTORS
Male gender
Staying single
Previous suicidal attempts
Depression
⁕Presence of guilt, nihilistic ideation,
worthlessness
⁕Higher risk after response to treatment
⁕Higher risk in the week after discharge

21. Suicidal preoccupation
Alcohol or drug dependence
Chronic illness
Recent serious loss or major
stressful life event
Social isolation
Higher degree of impulsivity

22. WARNING SIGNS FOR SUICIDE

23. Appearing depressed or sad most of the time
Feeling hopeless, expressinghopelessness
Withdrawing fromfamilyand friends
Sleeping toomuch or too little
Making overt statements like“I can’t take it anymore”;“I wish I were
dead”
Loosing interest in most activities
Giving away prizedpossessions
Making out a will
Being preoccupiedwith deathor dying
Neglecting personal hygiene
Making covert statements like “it’s okay now, everything will be fine”; “I
wont be a problemfor much longer”

24. COMMON MISCONCEPTION ABOUT SUICIDE
ⱺPeople who talk about suicide do not
complete suicide
ⱺPeople who attempt suicide really want to
die
ⱺSuicide happens without any warning
ⱺOnce people decide to die by suicide,
there is nothing you can do to stop them
ⱺAll suicidal individuals are mentally ill.
ⱺOnce a person is suicidal, he is suicidal
forever

25. MANAGEMENT

26. Be aware of the warning signs
Monitor the patient’s safety needs
 Take all suicidal threats or attempts seriously
 Search for toxic agents such as drugs/ alcohol.
 Do not leave the drug tray within reach of the
patient
 Make sure that daily medication is swallowed
 Remove sharp instruments from the environment
 Do not allow the patient to bolt the door from
inside.
 Somebody should accompany to the bathroom.
 Patient should never be left alone

27. Remove straps and clothing such as belts
Spent time with patient; allow ventilation of
emotions
 Encourage to talk about his suicidal plans/
methods
 In case of severe suicidal tendency – sedation
 A ‘ no suicide’ agreement may be signed
Enhance self esteem by focusing on his
strengths.
Acute psychiatric emergency interview
Counseling and guidance

28. To deal with ongoing life stressors and
teaching new coping skills
Treatment of psychiatric disorders

29. VIOLENCE/EXCITEMENT/
AGGRESSIVE BEHAVIOR

30. Violence is by one
person on another. It is important to note
that most violent individuals are not
psychiatrically ill. Violence is most
commonly associated with psychiatric
disorder, personality disorder, drug
intoxication or withdrawal, mental
retardation.

31. Do’s
֎Do protect yourself
֎Unarm the patient
֎Keep the doors open
֎Do restraint if necessary
֎Assert authority
֎Show concern, establish rapport and
assure the patient

32. Don’ts
Do note keep potential weapon near the patient
Do not sit with back to the patient
Do not wear neck tie or jewellery
Do not keep any provocative family member or
friend in the room
Do not confront
Do not sit close to the patient

33. GUIDELINES FOR SELF
PROTECTION WHILE
HANDLING AN
AGGRESSIVE PATIENT

34. Never see the patient alone
Keep a comfortable distance away from patient
Be prepared to move
Maintain a clear exit route
Be sure that the patient has no weapons with him
If patient is having a weapon, ask him to keep it
down rather than fighting with him
Keep something (pillow, mattress, blanket)between
you and weapon.
Distract the patient to remove the weapon (eg;
throwing water on the face)
Give prescribed antipsychotics

35. MANAGEMENT
Untie the patient, if tied up
Reassurance
oTalk to the patient softly
oFirm and kind approach is essential
oAsk direct and concise questions
oAvoid yes or no questions
oAssist the patient in defining the problem
Sedation
oChlorpromazine 50-100 mg IM
oHaloperidol 2-10 mg IM/IV
oDiazepam 5-10 mg slow IV

36. Collect detailed history and explore the cause
Carry out complete physical examination
Check hydration status; if severe dehydration– IV
fluids
Have less furniture in the room, remove all sharp
instruments
Keep environmental stimuli to the minimum
Stay with the patient to reduce anxiety
Redirect violent behavior with physical outlets such
as exercise, outdoor activities
Encourage the patient to ‘talk out’ the aggressive
feelings rather than acting them out.

37. GUIDELINES
oApproach patient from front
oNever see a potentially violent patient alone
oHave a 4 member team to hold each extremity
oKeep talking while restraining
oDo not leave the unattended after restraining
oObserve every 15 minutes for any numbness,
tingling or cyanosis in the extremities.
oEnsure that nutritional and elimination needs
are met.

38. STUPOR AND CATATONIC
SYNDROME

39. DEFINITION
Stupor is defined as a state of
diminished consciousness in which the
patient remains mute and still although the
eyes remain open and many follow external
objects.
Catatonic states may manifest through
negativism, catalepsy, mutism , stereotypes,
verbigeration, echolalia and echopraxia,
and impulsiveness.

40. MANAGEMENT
•Ensure patent airway
•Maintain hydration (Ryle’s tube feeding or IV fluids)
•Check vital signs
•History and physical examination
•Draw blood for investigation before starting any
treatment
•Identify the specific cause and treat
•Provide care for an unconscious patient
•Care of skin, nutrition, elimination and personal
hygiene is required
•Give ventillatory support if needed.

41. PANIC ATTACKS

42. Episodes of acute anxiety and panic
– occur as a part of psychotic or
neurotic illness

43. MANIFESTATIONS
Palpitations
Sweating
Tremors
Feelings of choking
Chest pain
Nausea
Abdominal distress
Fear of dying
Paresthesia
Hot flushes

44. MANAGEMENT
Give reassurance
Search for causes
Inj. Diazepam 10 mg or Lorazepam 2 mg
Counsel the patient and relatives
Use behavior modification techniques

45. VICTIMS OF DISASTER

46. People who have survived a
sudden, unexpected,
overwhelming stress

47. FEATURES
Depression
Flashbacks
Confusion
Numbness
Guilt
Frustration
Anger

48. MANAGEMENT

49. Treatment of the life threatening physical problem
Intervention
Listen attentively
Do not interrupt
Acknowledge understanding of the pain& distress
Look into their eyes
Console them – patting on the shoulders / touching
/holding their hands
Use silence
Do not ask them to stop crying
Provide accurate and responsible information
Group therapy
Benzodiazepines to reduce anxiety

50. Referral to mental health service, if
required.
Educate about the available resources
Teach them that these reactions are
normal to these type of situations.
Teach coping strategies to avoid the
development of crisis.

52. A hysteric may mimic abnormality of any
function, which is under voluntary control. The
common modes of presentation may be:
Hysterical fits
Hysterical ataxia
Hysterical paraplegia

54. MANAGEMENT

55. All presentations are marked by a dramatic quality and
sadness of mood.
Hysterical fit must be distinguished from genuine
fits.
As hysterical symptoms can cause panic among
relatives, explain to the relatives the psychological
nature of symptoms. Reassure that no harm would
come to the patient
Help the patient realize the meaning of symptoms,
and help him find alternative ways of coping with
stress.
Suggestion therapy with IV pentothal may be helpful
in some cases.

56. TRANSIENT SITUATIONAL
DISTURBANCES

57. These are characterized by disturbed
feelings and behaviour occurring due to
overwhelming external stimuli.

58. MANAGEMENT:
Reassurance
Mild sedation if necessary
Allowing the patient to ventilate his/her
feelings
Counseling by an understanding professional

59. DELIRIUM
TREMENS

60. Delirium tremens is an acute condition
resulting from withdrawal of alcohol.

61. MANAGEMENT:
⁂Keep the patient in a quiet and safe
environment.
⁂Sedation is usually given with diazepam
10mg or lorazepam 4mg IV, followed by
oral administration.
⁂Maintain fluid and electrolyte balance.
⁂Reassure patient and family

63. Following epileptic attack patient may
behave in a strange manner and become
excited and violent
MANAGEMENT:
※Sedation: Inj. Diazepam 10 mg IV [or]
Inj. Luminal 10 mg IV followed by oral
anticonvulsants
※Haloperidol 10 mg IV helps to reduce
psychotic behaviour.

64. ACUTE DRUG-INDUCED
EXTRAPYRAMIDAL
SYNDROME

65. Antipsychotics can cause a variety of
movement- related side-effects,
collectively known as Extra Pyramidal
Syndrome (EPS). Neuroleptic
malignant syndrome is rare but most
serious of these symptoms and occurs
in a small minority of patients taking
neuroleptics, especially high- potency
compounds.

66. •The drug should be stopped immediately.
Treatment is symptomatic and includes
cooling the patient, maintaining fluid and
electrolyte balance and treating
intercurrent infections.
•Diazepam can be used for muscle
stiffness. Dantrolene, a drug used to treat
malignant hyperthermia, bromocriptine,
amantadine and L- dopa have been used.
MANAGEMENT

67. DRUG TOXICITY

68. Drug over-dosage may be accidental or
suicidal. In either case all attempts must be
made to find out the drug consumed. A
detailed history should be collected and
symptomatic treatment instituted.
A common case of drug poisoning is
lithium toxicity. The symptoms include
drowsiness, vomiting, abdominal pain,
confusion, blurred vision, acute circulatory
failure, stupor and coma, generalized
convulsions, oliguria and death.

69. MANAGEMENT
•Administer Oxygen
•Start IV line
•Assess for cardiac arrhythmias
•Administer anticonvulsants
•Refer for haemodialysis

70. CONCLUSION

71. Psychiatric emergencies are often, but not
always, caused by mental illness. They
require action without delay to save the
patient and other persons from mortal
danger or other serious consequences .
Immediate treatment directed against the
acute manifestations is needed, both to
improve the patient’s subjective symptoms
and to prevent behavior that could harm the
patient or others.