2. Overview
• Safety and violence in the ER setting
• Definition of ‘emergency psychiatry’
• Physical restraints
• Pharmacologic support
• Suicide
• Psychosis, affective disorders,
substance use and personality
disorders
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3. General safety measures in
the ER
Keep your eye on your immediate
surroundings!
• Look for potential weapons such as
things that can be thrown
• Look for objects that the patient
could use for self harm
• Give yourself and the patient equal
access to the door
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4. Definition
A psychiatric emergency is any unusual
behaviour, mood or thought, which if not
rapidly attended to, may result in harm to a
patient or others.
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5. Psychiatric emergencies arise in
the context of
Chronic psychiatric illness
Consequence of medical illness that
presents with psychiatric symptoms
Adverse drug reaction
Intoxication
Drug-drug interaction.
When a patient is the victim of severe physical
or emotional trauma, and is unable to respond
adequately without professional intervention.
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6. Where does it occur?
A psychiatric emergency may occur in a home, on the
street, in an outpatient department, on a psychiatric
unit, on a medical or surgical unit of a general
hospital, or in the emergency department.
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7. Laboratory Studies to Assess
Potential Organic Causes of
Acutely Altered Behavior
Complete blood count
Electrolytes
Blood alcohol concentration or breath analyzer
Blood glucose concentration
Calcium level
Urine assay for substances of abuse
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8. Common Medical Illnesses That
Often Present as Psychiatric
Emergencies
Hypothyroidism
Hyperthyroidism
Diabetic ketoacidosis
Hypoglycemia
Urinary tract infection
Pneumonia
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9. Common Medical Illnesses
That Often Present as
Psychiatric Emergencies Cont.
Myocardial infarction
Alcohol intoxication
Alcohol withdrawal
Chronic obstructive pulmonary disease
Acute liver disease
Substance withdrawal
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10. Common Psychiatric Emergencies
• Abuse of child or adult
• Adjustment disorder Adolescent crises
• Akathisia,acute dystonia
• Alcohol intoxication or withdrawal
• Amnesia, anxiety, delirium, dementia
• Catatonia
• Family crises, marital crises
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12. Back to safety issues in the
Psychiatric emergency room!
• The comfort zone for most people is
hand shaking distance.
The comfort zone for paranoid or agitated
patients may be 2-3 X the usual distance.
• Remember the patients’ history when
you are in their personal space. When
you do a physical exam and you invade
their space they may react defensively.
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13. Assessing the risk of violence
• Immediate past, recent past and
more distant history of violence is
the best predictor of future
violence.
• Circumstances of violence and
characteristics of people involved are
important.
• Substance dependence or abuse
carries a 30X increase risk than the
general population!!
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14. .
• Antisocial personality disorder with
comorbid substance abuse or
dependence carries greater than
100X the risk compared to the
general population.
• Mental illness carries a 9X greater
risk than the general population
particularly paranoid schizophrenia
and confused states related to
medical problems.
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15. Clinical factors associated with violence
• A history of violent acts
• Inability to control anger
• History of impulsive behavior (reckless)
• Paranoid ideation or frank psychosis
• Lack of insight in psychotic patients
• Command hallucinations
• The stated desire to hurt or kill a person
• Acting out PD (Antisocial, Borderline)
• Presence of dementia, delirium or intoxication
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17. Behavioral Predictors of violence
• Angry words
• Loud language
• Abuse language
• Physical agitation such as making
fists,pacing and akasthisia
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19. Managing the Violent
Patient
• Hospital or clinical setting:
• Staff:
– Sufficient in number
– Well trained in seclusion & restraint techniques
• Seclusion & restraint is a measure to prevent injury to
the patient and other, not a punishment!!
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20. De-escalation of
agitated/violent patient
• The initial approach to a person with behavioural
disturbance should be focused on attempts to de-escalate
the behaviour.
• It takes the form of a verbal loop in which the clinician
actively listens to the patient, finds a way to respond that
agrees with or validates the patient’s position as far as
possible, and then explains what the clinician wants the
patient to do
• All staff involved in this process should be trained and
skilled in de-escalation.
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21. De-escalation technique
• Approach in a calm, confident and non-threatening
manner, with a non-aggressive stance with arms relaxed.
• Be empathic, non-judgemental and respectful. Listen to
the patient’s concerns.
• Introduce yourself, your role and the purpose of the
discussion, lead the discussion and engage the patient.
While other staff should remain in the vicinity to offer
support, it is imperative that only one staff member
verbally engage the patient
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22. Cont…
• Emphasise your desire to help. Ask what they want and
what they are worried about.
• Focus on the here and now, identify what is achievable,
rather than declining all requests, small concessions can
build trust and rapport.
• Avoid potentially provocative statements such as “calm
down” or “if you don’t settle down ….x will happen”
“you’d better stop that right now…or else” as this is likely
to escalate the patients behaviour in response to the
perceived threat.
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23. How to de-escalate a patient
• Use a calm voice
• Sit down with the patient
• Maintain adequate physical distance
of at least 6 feet
• Attempt to establish rapport
• Listen to the patient’s concerns
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25. When verbal de-escalation
is not enough;
• When there is risk of imminent harm
and verbal de-escalation has been
ineffective either pharmacologic
supports or physical restraints may
be needed.
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26. Physical restraints
• Have restraints, stretcher and
restraint keys ready
• Use a show of force with 5 or more
trained staff who may need to
physically lay hands on the patient.
Sometimes gathering that many
clinicians will persuade the patient to
comply.
• Try to have the patient into lying on
the stretcher
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27. .
• If the patient will not comply the
team will put the patient in
restraints.
• Remember people can bite and spit so
one of the team will control the head
during the restraining procedure.
• A minimum of two points ( one arm
and one leg).
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28. Once the patient is in
restraints;
• Search the patient for potentially harmful
objects such as lighters, knives or other sharp
items
• Perform a brief survey for any physical injuries to
the patient including head injury and observe
movement in all 4 limbs
• Check the head and eyes including eye movements
and pupillary response.
• Take the pt to seclusion room
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31. Pharmacologic Support:
Benzodiazepines
• Lorazepam is one of the most useful meds
in the emergency setting. In the first 24
hours agitation is as effectively addressed
with lorazepam as antipsychotics even if
psychosis is present.
• Lorazepam is best absorbed IM. Diazepam
and chlordiazepoxide have erratic
absorption. PO or IV administration of
diazepam is effective and actually has a
more rapid absorption than PO lorazepam.
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32. .
• The primary reason not to use a
benzodiazapine is its sedative hypnotic
effect which can be additive with other
such agents (ex. Alcohol) resulting in
excessive sedation and respiratory
depression.
• Patients can have a paradoxical reaction
and actually become more agitated. This is
seen in about 5% of the population.
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34. Rapid tranquilization
Principles
• Use oral, then IM as necessary.
• The intramuscular route is preferred over the intravenous
one from a safety point of view. ƒ
• Vital signs must be monitored after parenteral treatment is
administered. ƒGive small amounts. It is far easier to deal
with not giving enough than giving too much. Always
give time for the drug to work.
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35. Cont…
• Mixing drugs in the same syringe is hazardous and must
NEVER be done. ƒ
• Consider concurrent antipsychotics and the potential risk
of inadvertent high dose therapy. ƒ
ƒ
• Consider any on-going physical risks in relation to other
medical disorders, other drug treatment and any potential
for substance misuse.
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36. Treatment choices of RT
• If a patient has previously responded to a particular drug
for rapid tranquillisation, use again. ƒ
• If the patient is antipsychotic naïve, use low doses and
monitor for response and side effects closely. ƒ
• Oral medication should be considered initially.
• IM preparations currently recommended for use in rapid
tranquillisation are lorazepam, haloperidol and IM
olanzapine. In general, IM lorazepam is preferred. ƒ
• When using an IM typical antipsychotic agent, such as
haloperidol, an anticholinergic agent should be routinely
available to manage dystonia and other extrapyramidal
side effects.
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37. Extrapyramidal symptoms(EPS)
• Haloperidol is the most likely to cause
extrapyramidal symptoms (eps) followed
by risperidone with the other atypicals
having less eps risk.
• EPS is most likely to occur in young males
and older women.
EPS is usually noted as muscle tightness in
limbs,tongue thickness and neck tightness.
More rarely laryngeal and pharyngeal
spasm and a sense of choking.
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38. EPS treatment
• Be ready to give O2 if breathing problems develop
• PO, IM or IV diphenhydramine (Benadryl) 50mg q
4-5 hrs. IV form acts very quickly so great to use
if pt has IV access already. If not may need to
use IM. IM takes about 30 minutes to improve sx
and po takes around 60 minutes.
• Benztropine (Cogentin) 1-2mg PO or IM q 8-12
hours.
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40. Cont…
– Specific Rx for NMS:
• Levodopa-carbidopa
• bromocriptine
• Dantrolene
Course and prognosis
• symptoms evolve over 24 to 72 hours
• untreated syndrome lasts 10 to 14 days
• mortality rate can reach 10 to 20 % even
higher.
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42. Causes
This may occur in the following conditions
Depressive illness
Schizophrenia
Dissociative (Conversion) disorder
Dementia
Under the influence of alcohol and/or drugs
Following rape
Acute psychotic state
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43. Suicide behavior
Comprises the following elements
Wish to die
Wish to commit suicide
Communication of the intention to commit
suicide
Making suicide plan
Execution of suicide plan
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44. Motives/Reason for deliberate
self-harm
• To die
• Escape from unbearable anguish
• Get relief
• Change the behavior of others
• Escape from a situation
• Show desperation to others
• Get back at other people/make them feel guilty
• To Get help
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45. Methods of committing
suicide
Hanging
Ingesting poison or inhaling poisonous substance
Jumping from height
Drowning
Using guns
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46. Prevalence
80 people commit suicide every hour world wide.
Up to 40% of the general population experience the
wish to die at least once in their lifetime.
In Ethiopia,
• 0.9-3.2% of the general population attempt
suicide
• Prevalence of completed suicide is 7.7/100,000
persons per year.
• The rate for those 15 to 24 years of age has
increased two- to threefold.
• Suicide is currently ranked the 8th overall cause
of death in the United States.
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47. Etiology
95% of suicides occur within the context of
a mental disorder, particularly depression.
Difficulties in interpersonal relationships
Adverse socioeconomic circumstances
Chronic physical illness e.g. cancer,
HIV/AIDS
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48. Risk Factors
High
Negative ideas about life-hopelessness
Presence of mental illness particularly depression
Presence of suicidal behavior
Previous history of suicide attempt
Family history of suicide attempt or completed
suicide
Presence of general medical illness
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49. Risk Factors cont…
Others
Sex: more males commit suicide than females
Age: those aged more than 44 years tend to
commit rather than attempt suicide
Concomitant alcohol and other drug abuse
raise the risk of suicide
Loss of rational thinking as occurs in delirium,
schizophrenia or manic excitement raises the
risk of suicide.
Poverty and unemployment
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50. Risk factors
• Psychiatric
– Depression
– Schizophrenia
– Alcohol & other substance use problems
– Panic disorder
– Personality disorder – cluster B, impulsive &
unstable
– Co morbidity
– Tend to be young, & when admitted suicide
rate highest in the 1st week of admission and
the 1st 3-6 months after discharge.
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51. Risk factors cont…
• Social
– "the suicide rate varies inversely with the integration of social
groups of which the individual forms a part.“
Egoistic suicide - a lack of meaningful family ties or social
interactions. Due to an individual see being alone or an
outsider.
– These individuals are unable to find their own place in
society and have problems adjusting to groups.
– They received little and no social care. Suicide is seen
as a solution for them to free themselves from
loneliness or excessive individuation.
–
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52. Anomic suicide - relationship between an individual and
society is broken by social or economic adversity.
Caused by the lack of social regulation and it
occurs during high levels of stress and
frustration.
For example, when individuals suffer extreme
financial loss, the disappointment and stress that
individuals face may drive them towards
committing suicide as a means of escape.
Altruistic suicide: results from excessive integration in
society. It occurs when social group involvement is
too high.
Individuals are so well integrated into the group
that they are willing to sacrifice their own life
in order to fulfil some obligation for the group.
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53. Individuals kill themselves for the collective
benefit of the group or for the cause that the
group believes in.
An example is someone who commits suicide for
the sake of a religious or political cause
Fatalistic suicide: occurs when individuals are kept under tight
regulation.
These individuals are placed under extreme rules or high
expectations are set upon them, which removes a person’s
sense of self or individuality.
Slavery and persecution are examples of fatalistic suicide
where individuals may feel that they are destined by fate to be in
such conditions and choose suicide as the only means of
escaping such conditions.
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55. Risk factors cont…
• Psychological
– Aggression turned inward against an introjected,
ambivalently cathected love object.
– Loss of a love object or have sustained a narcissistic
injury, who experience overwhelming moods like
rage and guilt, or who identify with a suicide victim
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56. Risk factors cont…
• Biological
– Reduced central serotonin is associated with suicide
– Genetics
– Physical disorders CNS (epilepsy, MSL, head injury,
CVD, Huntington, dementia, HIV/AIDS). Endocrine
(Cushing’s). GI (Ulcer, Cirrhosis). GUT (Prostatic
hypertrophy, end-stage renal disease). Any chronic
intractable pain -
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57. Communication of
suicide wish
Direct communication
• “if you think that I am not the head of this home, I
will leave this world for you.”
Indirect communication
• “I am fade up with life”; “I wish I were not born”
Suicide note
• the presence of suicide note for a previous attempt
• plan to leave a suicide note before executing a
planned suicide act
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58. Assessment of suicide risk
A highly suicidal patient
Is severely depressed or has overt signs of florid
psychosis
Has attempted or tried to attempt suicide before
coming to you
Has an urgent wish to die, possibility within the
week or so; natural death is too far
Has active plans for implementing suicide plan
Will feel disappointed if suicide bid fails
May have communicated the suicide intention to
someone else.
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60. Management
• Detect suicide behavior in every patient with clinical
interview.
• Detect the presence of psychiatric disorder
Depression
Chronic general medical illness
Psychosocial stressors.
• Start medication for appropriate psychiatric disorder
Dispense drugs on weekly basis only till the risk of
suicide has substantially been removed
• Discuss the prevention of suicide behavior with colleague in-
charge of general medical care (as appropriate)
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61. Management cont…
Dealing with
Interpersonal problems and psychosocial stressors – current
and ongoing
• Narrate the nature of his/her current and ongoing life
difficulties
• Describe his/her previous, current or ongoing stressors
• Develop hierarchy of his/ her usual responses to life
stressors
• Evaluate the effectiveness of each of these responses
• Develop alternative responses and strategies his/her
difficulties, etc
• Develop homework for the patient to carry out
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62. Management plan
• In-pt vs. Out-pt
• social support?, impulsive behavior? Suicidal
plans?
• Remove or treat risk factors
• underlying medical problems (delirium 20
treatable conditions, alcohol and substance
abuse/withdrawal etc)
• physical (in unpredictable and impulsive
patients) &/or chemical restraint (anxiolitics,
antidepressants, neuroleptics)
• Psychotherapy (supportive, family therapies)
• Electroconvulsive therapy (ECT)
• REFER the pt where he/she can be best helped
for follow-up
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63. Take home points
• Safety is always the first concern in
the emergency setting.
• To maintain safety both physical
restraints and pharmacologic support
may be needed.
• Assess carefully for suicide.
• Screen for addiction, affective,
psychotic and personality disorders.
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