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1. Psychiatric Emergencies
Nabina Paneru

2. Introduction
• An emergency is defined as an unforeseen combination of circumstances
which calls for an immediate action.
• A psychiatric emergency is a disturbance in thought, affect, and
psychomotor activity leading to a threat in his existence or threat to the
people in the environment.

3. Contd.
• Edwin Shneidman proposed that victims of suicide suffer unbearable
psychological pain, a sense of isolation, and the perception that death is
the only solution to their situation. Individual feels that there is no way
out.
• This condition needs immediate intervention to safeguard the life of the
patient, bring down the anxiety of the family members and emotional
security to others in the environment.

4. Common psychiatric emergencies
• Attempted suicide
• Excitement and violence
• Stupor and catatonic syndrome
• Severe depression
• Panic attacks
• Dissociative convulsion
• Neuroleptic malignant syndrome
• Lithium toxicity
• Drug and alcohol withdrawal

5. ANGER, AGGRESSION AND VIOLENCE
Anger-An emotional state that may range in intensity from mild
irritation to intense fury and rage. It is an emotional response to
something that has happened or is happening.

6. Contd.
Aggression-The act of initiating hostilities, a feeling of hostility that
arouses thoughts of attack and disposition to behave aggressively.

7. Contd.
Violence- Is defined as an unjust, unwarranted, or
unlawful display of force to inflict harm upon,
damage or violate.

8. Etiology
a) Social factors: childhood aggression, alcohol and substance
abuse, poor socioeconomic status, male gender and young age
b) Neurobiological factors: structural damage to the limbic system,
low central serotonin function has been correlated to aggression
and impulsive activities

9. Contd.
c) Genetic linkage
d) Psychiatric disorders: common in mania, depression, drug and
alcohol dependence, epilepsy, acute stress reaction, organic
psychotic reaction.

10. Signs and symptoms
• Angry
• Irritable
• clenched teeth
• Hyperactive
• Increasing anxiety and tension
• Verbal abuse
• Loud voice
• Intense eye contact
• Stone silence

11. Treatment and management

12. Pre-assaultive stage
• During the pre-assaultive stage the patient becomes increasingly
agitated.
• Staff require training in both verbal techniques of de-escalation
and physical techniques to restrain without harm.

13. Contd.
1. Pay attention to the angry behavior and respond as early as possible
2. Assess personal safety and provide self-care
Leave door open
Choose a quiet place
If you are uncomfortable have another staff nearby
Always use more space if the patient is anxious.
Know where panic buttons and alarms are located
Never turn your back on an angry patient.

14. Contd.
3. Appear calm and control- the perception that someone is in control can be
comforting and calming to an individual who is beginning to lose control
4. Do not try to speak when aggressive patient is yelling. It will only escalate
the anger and violence
5. Speak softly in a nonprovocative, nonjudgmental manner
6. Demonstrate genuineness and concern- do not treat individual in a
humiliating manner
7. Set clear, enforceable limits on behavior. “It’s okay to be angry with Ramesh,
but it is not okay to threaten him.”

15. Contd.
8. If patient is willing, both nurse and the patient can sit in a 450angle. Do not
tower over or stare at the patient.
9. When the patient begin to talk, listen. Use clarification.
10.Acknowledge the patients need regardless of whether expressed needs are
rational or irrational, possible or impossible to meet.

16. Assaultive stage
• In this stage, the patient shows violence.
• If the patient progresses to assaultive stage then the nurse should immediately
respond.
• Generally a team approach with at least 5 members is advisable. Only leader
speaks to the patient and instruct the members of the team.

17. Assaultive stage Contd.
• The intervention includes medication, seclusion or physical restraint.
• APNA 2002 Seclusion and Restraint Standards of Practice- Any staff
providing care to persons at risk of harming others and themselves and who
participate in seclusion and restraint shall have received training and
demonstrate current competency in all aspects of dealing with behavioral
emergencies.
• Be sure to know the hospital protocol for seclusion and restraints in whatever
part of the hospital you choose

18. Contd.
• Medications- antipsychotics, benzodiazepines. Haloperidol is the first choice
among antipsychotics and lorazepam is the choice among BZD.

19. Contd.
• Seclusion- It is the voluntary confinement of a person alone in a room or an
area where a person in physically prevented from leaving. Used for
management of violent self-destructive behavior.

20. Contd.
• Restraints- It refers to any manual method, mechanical device or equipment
attached or adjacent to a patient’s body where they cannot move their arms,
legs, body or head freely.
* Seclusion and restraints is only used after alternative interventions have been
attempted (e.g. medication, verbal intervention, decreased sensory stimulation,
removal of a stimulus, and use of sitter who provides one to one 24 hours
observation of the patient).

21. Contd.
• Seclusion and restraints are used in the following circumstances
- The patients presents a clear danger to self and others
- The patient is legally detained for involuntary treatment and is thought to pose
an escape risk.
- The patient requests to be secluded or restrained.

22. Contd.
- Once in restrain the patient must be protected from all sources of harm.
- Each team member is trained with a correct use of physical restraining maneuvers
as well use of physical restraints.
- Before approaching the patient, the team is prepared with the correct number and
size of restraints and with medication, if ordered.
- The team leader explains to the patient in a straightforward manner exactly what
the team is about to do and why.
- Face to face observation is made every 15 mins and reintegration occurs gradually.

23. Post assaultive stage
When the patient returns to the baseline
• Critical incident debriefing- staff analysis of an episode of violence is crucial.
To ensure that quality care was provided to the patient. Prevent long term
psychological sequel.

24. Contd.
• Documentation of violent episode- assessment of the behaviors, nursing
interventions, evaluation of the interventions used, patient’s response to those
interventions, interventions performed while the patient was in seclusion
room.
• Anticipating increased anxiety and anger in other hospital settings
• Use of anxiety reduction techniques
• Psychotherapy

25. STUPOR AND CATATONIC SYNDROME
Stupor- Is defined as a syndrome of mutism and akinesis but with relative
preservation of conscious awareness. Stupor is a condition in which a person is
motionless for a long period of time and may appear to be in coma.
Catatonia- Is defined as extreme abnormal motor behavior. It can be either
excited, withdrawn or mixed.

26. Etiology
• Neurological disorders like epilepsy, cerebral malaria, neoplasms,
• Systemic and metabolic disorders-DKA, pellagra, hyperparathyroidism, SLE,
membranous glomerulonephritis

27. Contd.
• Drugs and poisoning- anti psychotics, ACTH, aspirin, ethyl alcohol, lithium
toxicity
• Psychiatric disorders- catatonic schizophrenia, depressive stupor, manic
stupor, conversion and dissociative disorder, reactive psychosis, during
hypnosis
• Onset is abrupt and the prognosis is favorable.

28. Clinical features of excited catatonia
• Increase in psychomotor activity- restless, agitation, excitement,
aggressiveness, violent at times.
• Increase in speech production
• The person may run ceaselessly and without purpose leading to exhaustion
and cardiac difficulties or physical collapse.
• Automatic obedience, mannerism, impulsiveness, excitement, nudism.
• Extreme motor agitation

29. Clinical features of retarded (stuporous) catatonia
• Mutism - complete absence of speech
• Rigidity- maintenance of rigid posture against all commands and efforts to be
moved. The person does not move or eat, thus becoming vulnerable to
pressure ulcers, contractures and malnutrition

30. Contd.
• Negativism- resistance to all commands and attempts to be moved, doing just
the opposite
• Posturing – voluntary assumption of bizarre posture such holding arms or legs
rigidly or bent at severe angle for a long period of time.
• Stupor- akinesis with mutism with evidence of relative preservation of
consciousness

31. Contd.
• Echolalia- mimicking of phrases or words
• Echopraxia- mimicking of actions
• Waxy flexibility- parts of the body can be placed in positions that will be
maintained for a long period of time, even if very uncomfortable.
• Other behavior like automatic obedience, mannerism

32. Treatment
Treatment of underlying cause
Ensure patency of airways and oxygenation
Check cardiac activity and vital signs
Provide IV fluids for possible fluid and electrolyte imbalance
Maintain circulation

33. Contd.
Treat hypoglycemia
Benzodiazepines are the first line of therapy for catatonic syndrome
Use of antidote for drugs poisoning
Electroconvulsive therapy is sometimes used
Rarely restraining