This document discusses the management of behavioral emergencies in psychiatry. It covers creating a safe environment, assessing agitation levels, pharmacological interventions including benzodiazepines and antipsychotics, and physical restraint as a last resort with proper training and personnel. The goal is rapid control of agitation while prioritizing patient and staff safety.

1. DR.SOUMITRA DAS

2. EMERGENCY PSYCHIATRY
 THE PHYSICIAN DEALS WITH SITUATIONS FOR WHICH
IMMEDIATE THERAPEUTIC INTERVENTION FREQUENTLY
NECESSARY.

3. PSYCOMOTOR AGITATION
PSYCHOMOTOR AGITATION IS DEFINED AS A STATE OF MARKED
MENTAL EXCITATION ACCOMPANIED BY PURPOSELESS MOTOR
ACTIVITY, WHICH MAY VARY FROM SLIGHT RESTLESSNESS TO
VIGOROUS UNCOORDINATED MOVEMENTS.

4. EPIDEMIOLOGY
 EQUALS 5 TO 7 % OF ALL EMERGENCIES
 MORE MALES

5. ASSESSMENT
 REQUIREMENTS:
 PERSONAL QUALITIES
 WELL EQUIPPED UNIT(SECURITY OFFICERS,TRAINEN PERSONS)

6. IMPORTANT EVALUATIONS
 LETHALITY
 SUICIDAL AND HOMICIDAL IDEATION,INTENT,ATTEMT
 LEGAL RIGHT(CONSEQUENCES OF CIVIL COMMITMENTS)
 FACTORS TRIGGERING HOSPITALISATION
 NEED FOR CHEMICAL/PHYSICAL RESTRAINS

7. DESIRED FORTITUDE FOR
CLINICIANS
 INTINCTS FOR DANGER
 TOLERANCE
 EMPATHY NOT SYMPATHY
 SELF ASSERTION
 HONESTY
 RESOURSEFULLNESS AND NETWORKING
 CREATIVITY
 ENDURANCE
 HUMOR
 PRAGMATISM

8. SAFE ENVIRONMENT
 SPECIAL INTERVIEW ROOM: TWO EXIT DOORS,NO
WIRES/TUBES,CEILING NOT
REACHABLE,NONREMOVABLE MATERIALS,FIVE
STAFFS,VISUAL MONITORING,BOLTED DOWN
FURNITURE,ISOLATION ROOM,RESTRAINS MATERIALS.
 SCRENING WEAPONS
 PANIC BUTTONS
 CODING SYSTEM
 SECURITY STAFFS NEAR ENTRANCE

9. INTERVIEW
 ASSESS THE SCENE
 BE PREPARE TO SPEND EXTRA TIME
 SAFE DISTANCE,SITTING ON 45 DEG ANGLE
 CALM ,HONEST
 METHODICAL(SHOW INTEREST IN PT’S STORY)
 NONJUDGEMENTAL
 RAPPORT

10.  OPEN ENDED QUESTIONS
 AVOIDING DIRECT EYE CONTACT,AVOID FRIGHTENING
 EXCLUDE DISRUPTIVE PEOPLE
 ENCOURAGE PURPOSEFUL MOVEMENTS
 AVOIDING CHALLEGING
 DEVELOP A PLAN OF ACTION.
 ONCE THE PLAN IS SET, ALLOW THE PATIENT TO EXERCISE
SOME CONTROL

11. INTERVIEW COURSE
 GENERAL QUESTIONS
 ASSESSMENT OF DELIRIUM
 SUICIDAL IDEATIONS
 MEDICAL ILLNESS
 PRESENT MEDICATIONS
 H/O POISONING
 PAST/FAMILY HISTORY/SOCIAL SUPPORT/COLLATERAL
INFORMATIONS
 MSE

12. MSE
 CONSCIOUSNESS
 LEVEL
 CONCENTRATION
 ORIENTATION
 YEAR/MONTH
 LOCATION
 ACTIVITY
 APPEARANCE,BEHAVIOR
 MOVEMENT
 SPEECH
 RATE, VOLUME, FLOW,
ARTICULATION, AND
INTONATION

13. MSE
 THOUGHT
 IS THE PATIENT MAKING
SENSE?
 MEMORY
 RECENT
 REMOTE
 IMMEDIATE
 AFFECT AND MOOD
 DO THE INNER FEELINGS
SEEM APPROPRIATE?
 PERCEPTION
 “DO YOU HEAR THINGS
OTHERS CAN’T?”

14. SECONDARY ASSESSMENT
 In examining the
extremities, check for:
 Needle tracks
 Tremors
 Unilateral weakness or
loss of sensation
 OBTAIN VITAL SIGNS.
 EXAMINE SKIN
TEMPERATURE AND
MOISTURE.
 INSPECT THE HEAD AND
PUPILS.
 NOTE UNUSUAL ODORS ON
THE BREATH.

15. ASSESSING AGITATION
 SHOULDN’T BE RESTRAINED OR MEDICATED IMMEDIATELY.
 DETERMINE THE PT’S “RISK OF ESCALATION.”
 FOUR STAGES OF AGITATION
 STAGE 1: THE AGITATION IS MODIFIED BY VERBAL CUES, WITHOUT
LIMITS OR BOUNDARIES BEING INVOKED.
 STAGE 2: THE AGITATION IS CONTAINED VERBALLY THROUGH LIMIT-
SETTING, BUT IT PERSISTS NONETHELESS.
 STAGE 3: THE AGITATION SUBSIDES DURING TRANSIENT PHYSICAL
RESTRAINT.
 STAGE 4: THE AGITATION REQUIRES PHARMACOTHERAPY. IT IS
OTHERWISE INTRACTABLE.
 OFTEN STAGES 3 AND 4 ARE CONFLATED.

16.  ALWAYS HAVE AN EXIT STRATEGY, AND ENSURE THAT
OTHERS CAN QUICKLY COME TO YOUR ASSISTANCE,
IN CASE THAT’S REQUIRED.
 NEVER PLAY HERO(INE) AND TAKE THINGS INTO YOUR
OWN HANDS!

17. CRITERIA FOR HOSPITALISATION
 DANGER TO SELF/OTHER
 POOR SELF CARE/BREAKDOWN OF SUPPORT SYSTEM
 EXTREME DISTRESS OR CRISIS
 EXACERBATION OF PSYCHIAYTRIC ILLNESS
 CLARIFICATION OF DIAGNOSIS
 POOR INSIGHT/JUDGEMENT
 INTOXICATION
 REPEATED TREATMENT FAILURE
 FOR ECT

18.  IT IS IMPORTANT TO FORMULATE A TENTATIVE
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS TO GUIDE
TREATMENT.

19. MEDICAL CONDITIONS
ACUTE ONSET
FIRST EPISODE
GERIATRIC AGE
CURRENT MEDICAL ILLNESS OR INJURY
SIGNIFICANT SUBSTANCE ABUSE
NON-AUDITORY DISTURBANCES OF PERCEPTION
NEUROLOGICAL SYMPTOMS
COGNITIVE DYSFUNCTION
CONSTRUCTIONAL APRAXIA

20. MEDICAL AND PSYCHOLOGICAL CONDITIONS
THAT MAY PRESENT WITH VIOLENT BEHAVIOR
Medical Substance Induced
 CEREBRAL INFECTION
 CEREBRAL NEOPLASM
 ELECTROLYTE IMBALANCE
 HEPATIC DISEASE
 HYPOGLYCAEMIA
 HYPOXIA
 INFECTION
 RENAL DISEASE
 TEMPORAL LOBE EPILEPSY
 VITAMIN DEFICIENCY
 ALCOHOLIC INTOXICATION
 ALCOHOL WITHDRAWAL
 AMPHETAMINE INTOXICATION
 COCAINE INTOXICATION
 DELIRIUM TREMENS
 INHALANT INTOXICATION
 PHENCYCLIDINE (PCP)
INTOXICATION
 SEDATIVE/HYPNOTIC
WITHDRAWAL

21. PSYCHIATRIC
 ANTISOCIAL PERSONALITY DISORDER
 BIPOLAR DISORDER
 BORDERLINE PERSONALITY DISORDER
 CATATONIC SCHIZOPHRENIA
 DECOMPENSATING OBSESSIVE COMPULSIVE PERSONALITY DISORDER
 DELUSIONAL DISORDER
 DISSOCIATIVE DISORDER
 IMPULSE CONTROL DISORDER
 PARANOID PERSONALITY DISORDER
 SCHIZOPHRENIA
 SOCIAL MALADJUSTMENT WITHOUT PSYCHIATRIC DISORDERS
 UNCONTROLLABLE VIOLENCE SECONDARY TO INTERPERSONAL STRESS

22. IMPORTANT CONSIDERATIONS IN
DIAGNOSIS OF A VIOLENT BEHAVIOR IN
PATIENT
1. PATIENT’S PREMORBID PERSONALITY
2. PAST HISTORY
3. THE UNDERLYING DISORDER
4. THE SOCIAL SETTING

23. PHYSICAL AND PSYCHOLOGICAL CONDITIONS
THAT PRESENT WITH ALTERED MOOD.
PHYSICAL
ALCOHOL INTOXICATION
 ANTIHYPERTENSIVE
MEDICATION (E.G.,
METHYLDOPA, PROPRANOLOL,
RESERPINE TOXICITY)
 ANTIDEPRESSANT
MEDICATION
 BENZODIAZEPINE
INTOXICATION
 CARCINOMA OF PANCREAS
 CEREBRAL TUBERCULOSIS
 CEREBROVASCULAR SYPHILIS
 CESSATION OF AMPHETAMINE OR
COCAINE USE
 CIRRHOSIS OF THE LIVER
 CORTICOSTEROID TOXICITY
 DEGENERATIVE DISEASES OF THE
CENTRAL NERVOUS SYSTEM (E.G.,
ALZHEIMER’S DISEASE,
HUNTINGTON’S CHOREA, PICK’S
DISEASE)
 DIABETES
 ENCEPHALITIS

24.  HEPATIC FAILURE
 HEPATITIS
 HYPERPARATHYROIDISM
 HYPERTHYROIDISM
 HYPOKALEMIA
 HYPONATREMIA
 HYPOTHYROIDISM
 INFECTIOUS MONONUCLEOSIS
 MULTIPLE SCLEROSIS
 POSTVIRAL INFECTION SYNDROME
 RENAL FAILURE
 SUBDURAL HEMATOMA

25. PSYCHOLOGICAL
SCHIZOPHRENIA
 BIPOLAR MOOD ILLNESS
 REACTIVE DEPRESSION
 REACTIVE PSYCHOSIS
 SCHIZOAFFECTIVE

26. PHYSICAL AND PSYCHOLOGICAL
ILLNESS THAT PRESENT WITH ANXIETY
Medical
ALCOHOL WITHDRAWAL
 AMINOPHYLLINE USE
 AMPHETAMINE AND
SIMILAR SYMPATHAMIMETIC
 ANTIDEPRESSANT
WITHDRAWAL
 ANTIPSYCHOTIC DRUG
WITHDRAWAL
 BENZODIAZEPINE
WITHDRAWAL
 CAFFEINE INTOXICATION
DELIRIUM
 ENCEPHALITIS
 HYPERTENSION
 HYPERTHYROIDISM
 HYPOCALCAEMIA
 HYPOGLYCEMIA
 HYPOKALEMIA
 IMPENDING MYOCARDIAL
INFARCTION
 INTERNAL HEMORRHAGE

27.  LEAD INTOXICATION
 OPIATE WITHDRAWAL
 POST CONCUSSION SYNDROME
 TEMPORAL LOBE DISEASE

28. PSYCHOLOGICAL
 ADJUSTMENT DISORDER
WITH ANXIOUS MOOD
 AGORAPHOBIA WITH PANIC
ATTACKS
 AGORAPHOBIA WITHOUT
PANIC ATTACKS
 BIPOLAR MOOD ILLNESS
 BORDERLINE PERSONALITY
 EGO-DYSTONIC
HOMOSEXUALITY
GENERALIZED ANXIETY
DISORDER
 HOMOSEXUAL PANIC
 HYPERVENTILATION
SYNDROME
 OBSESSIVE-COMPULSIVE
DISORDER
 POST-TRAUMATIC STRESS
DISORDER
 SCHIZOPHRENIA
SOCIAL PHOBIA

29. Physical and Psychological Conditions
That Present with Disorganization of
Thought
Medical
ALCOHOL WITHDRAWAL
 AMPHETAMINE INTOXICATION
 ANTICONVULSANT
WITHDRAWAL
 ANTIDEPRESSANT
MEDICATION
 BACTERIAL MENINGITIS
 COCAINE INTOXICATION
DELIRIUM
 HYPERPARATHYROIDISM
 HYPERTHYROIDISM
 HYPOPARATHYROIDISM
HYPOTHYROIDISM
 LEAD INTOXICATION
 MERCURY INTOXICATION
 MIGRAINE HEADACHE
 MULTIPLE SCLEROSIS
STEROID TOXICITY
 SUBDURAL HEMATOMA
 SYSTEMIC LUPUS
ERYTHEMATOSUS
 TEMPORAL LOBE EPILEPSY

30. PSYCHOLOGICAL
ADJUSTMENT REACTION OF
ADOLESCENCE
 BIPOLAR MOOD ILLNESS
 CATATONIC SCHIZOPHRENIA
 CHRONIC UNDIFFERENTIATED
SCHIZOPHRENIA
 PARANOID SCHIZOPHRENIA
REACTIVE PSYCHOSIS
 SCHIZOAFFECTIVE DISORDERS
 SCHIZOPHRENIFORM
DISORDERS

31. MANAGEMENT OF BEHAVIORAL
EMERGENCIES

33. ENVIRONMENTAL
 PROTOCOL
 PERIODIC TRAINING
 RECYCLING
 SECURITY

34. ALTITUDINAL
 AVOID ABRUPT MOVEMENTS
 AVOID TAKING NOTES
 OWN INTRODUCTION WITH REASSURANCE
 ENCOURAGE TO EXPRESS FEELINGS
 LIMIT OF ACCEPTING MANNER

35. PHARMACOLOGICAL:
PRELIMINARY CONSIDERATIONS
 PM AGITATION
ASSESSMENT
 GROUP APPOARCH
 DESCRIBE REASON FOR
MEDICATIONS
 ORAL>PARENTERAL
 AGE/SEX
 MEDICAL ILLNESS/CI
 PREGNANCY
 BMI
 H/O MEDICATIONS/SIDE
EFFECTS

36. DRUGS
BENZODIAZEPINES CATIONS
 LORAZEPAM 1 OR 2
MG,PO/IM/IV
 FAST ACTING,
 EASY,DOSING,ABSORPTIO
N
 NO ACTIVE METABOLITES
 NO GLUCURONIDATION
 COPD
 SLEEP APNEA

37. ANTIPSYCHOTICS
HALOPERIDOL DROPERIDOL
 TYPICAL
 HIGH POTENCY
 CAN BE COMBINED
LORAZEPAM
 TO AVOID S/E:COMBINE
WITH
TRIHEXYPHENIDRYL/BENZ
TROPINE/DIPHENHYDRAM
INE
 SEDATION MORE RAPID
 PROLONG QT INTERVAL

38. DOSING OF TYPICALS
 CHLORPROMAZINE[DAILY PO50-400/INITIAL IM 25-
50MG]
 FLUPHENAZINE[DAILY PO2-20MG/INITIAL IM1.25-5MG]
 HALOPERIDOL[DAILY PO2.5-100/INITIAL IM2.5-10MG]
 MESORIDAZINE[DAILY PO100-400/INITIAL IM25-50MG]
 PERPHENAZINE[DAILY PO16-64/INITIAL IM5-10MG]
 THIOTHIXENE[DAILY PO15-60/INITIAL IM4-8 MG]
 TRIFLUOPERAZINE[DAILY PO4-20/INITIAL IM1-2MG]

39. ATYPICALS
 OLANZAPINE[30MG/DAY] IM
ZIPRASIDONE[40MG/DAY] IM
 RISPERIDONE 0.25-8 MG/DAY PO,IM LA
 QUETIAPINE 25-800/DAY PO
 ARIPIPRAZOLE 10-30MG/DAY PO
 CLOZAPINE 200-1000MG/DAY

40. PHYSICAL RESTRAINT
 IMPROVISED OR COMMERCIALLY MADE DEVICES
 BE FAMILIAR WITH RESTRAINTS USED BY YOUR AGENCY
 MAKE SURE YOU HAVE SUFFICIENT PERSONNEL
MINIMUM OF FIVE TRAINED, ABLE-BODIED PEOPLE
 DISCUSS THE PLAN OF ACTION BEFORE YOU BEGIN
 INCLUDE LAW ENFORCEMENT
 USE THE MINIMUM FORCE NECESSARY
 DON’T IMMEDIATELY MOVE TOWARD THE PATIENT

41. DO NOT
 TIE ANKLES AND WRISTS TOGETHER
 HOBBLE TIE
 PLACE A PATIENT FACEDOWN IN A REEVES STRETCHER

42. ONCE IN PLACE
 DON’T REMOVE RESTRAINTS.
 DON’T NEGOTIATE OR MAKE DEALS.
 PLACE A MASK OVER THE FACE OF A SPITTING PATIENT.

43.  CONTINUOUSLY MONITOR
THE PATIENT.
 NEVER PLACE YOUR PATIENT
FACE DOWN.
 CHECK PERIPHERAL
CIRCULATION EVERY FEW
MINUTES.

44. ADVERSE EFFECT CAN PRESENT
WITH AGITATION
SEROTONIN SYNDROME NEUROLEPTIC MALIGNANT
SYNDROME
 CAUSES-SSRI,SNRI,COMBINATIONS
OF MULTIDRUGS
 DIARRHEA/CONFUSION/DELIRIUM
/COMA/INSTABLE
ANS/TREMOR/RIGITY/MYOCLONU
S/AKI/DIC/ARDS/SEIZURE
 RFT/LFT/CPK/ECG/CBC/INR
 RX:DISCONTINUE
DRUGS/IVF/BDZ/ICU
 ANTIPSYCHOTICS
 HTN/DIAPHORESIS/TACHYCARDIA/
LIVER
FAILURE/AKI/MYOCLONUS/CONFU
SION/TREMOR/RIGIDITY/ATAXIA
 SEROLOGIC MARKERS INCLUDE
ELEVATED CK, DEMONSTRATING
RHABDOMYOLYSIS; METABOLIC
ACIDOSIS; AND LEUKOCYTOSIS
 RX:DISCONTINUATION/IVF/DANTR
OLENE/BROMOCRIPTINE/AMANTI
DINE/LEVODOPA/BENZTROPINE/C
LONAZEPAM/ECT

45. LITHIUM
TOXICITY
 ASSOCIATED WITH NAUSEA, VOMITING, DIARRHEA,
WEAKNESS, FATIGUE, LETHARGY, CONFUSION, SEIZURE,
AND POTENTIALLY COMA
 TOXICITY NOT ENTIRELY CORRELATED WITH SERUM
LITHIUM LEVEL; TOXICITY MAY DEVELOP AT DIFFERENT
LEVELS FOR DIFFERENT PEOPLE
 OBTAIN SERUM LITHIUM LEVEL, AND EKG
 ENCOURAGE HYDRATION; CONSIDER HEMODIALYSIS IN
EXTREME CASES

46. SPECIFIC SITUATIONS
SUICIDE: ANY WILLFUL ACT DESIGNED TO END ONE’S LIFE

47. Suicide Risk Factors
 PREVIOUS ATTEMPTS
 DEPRESSION
 AGE
 15–24 OR OVER 40
 ALCOHOL OR DRUG ABUSE
 DIVORCED OR WIDOWED
 GIVING AWAY BELONGINGS
 LIVING ALONE OR IN
ISOLATION
 PRESENCE OF PSYCHOSIS WITH
DEPRESSION
 MANIA
 F20
 HOMOSEXUALITY
 HIV STATUS
 MAJOR SEPARATION
TRAUMA
 MAJOR PHYSICAL STRESSES
 LOSS OF INDEPENDENCE
 LACK OF GOALS AND PLAN
FOR THE FUTURE
 SUICIDE OF SAME-SEXED
PARENT
 EXPRESSION OF A PLAN
FOR SUICIDE
 POSSESSION OF THE
MECHANISM FOR SUICIDE

48. SUICIDAL IDEATION
 ASSESSMENT
 EVERY DEPRESSED PATIENT MUST BE EVALUATED FOR
SUICIDE RISK.
 MOST PATIENTS ARE RELIEVED WHEN THE TOPIC IS
BROUGHT UP.
 BROACH THE SUBJECT IN A STEPWISE FASHION.
 DIAGNOSE HIGHER-RISK PATIENTS

50. DON’TS
 DON’T LECTURE, BLAME OR PREACH
 DON’T CRITICIZE CLIENT
 DON’T DEBATE THE PROS AND CONS OF SUICIDE
 DON’T BE MISLED BY CLIENT’S TELLING YOU THE CRISIS HAS
PASSED
 DON’T DENY THE CLIENT’S SUICIDAL IDEAS
 DON’T TRY TO CHALLENGE

51.  DON’T LEAVE CLIENT ISOLATED, UNOBSERVED OR DISCONNECTED
 DON’T DIAGNOSE AND ANALYZE BEHAVIOR OR CONFRONT PERSON
WITH INTERPRETATIONS DURING ACUTE PHASE
 DON’T BE PASSIVE
 DON’T OVER REACT
 DON’T KEEP CLIENT’S SUICIDAL RISK A SECRET
 DON’T GET SIDE TRACKED ON EXTERNAL ISSUES OR PERSONS
 DON’T GLAMORIZE, MARTYRIZE, GLORIFY OR DEFY SUICIDAL
BEHAVIOR IN OTHERS, PAST OR PRESENT
 DON’T FORGET TO TREAT THE PSYCHIATRIC ILLNESS
 DON’T FORGET TO FOLLOW UP

52. HOMICIDALITY
 RISK FACTORS:
 HISTORY OF VIOLENCE;
AGGRESSION
 IMPULSIVITY; INTOXICATION
 SINCERE PLAN
 COMMON ETIOLOGIES
INCLUDE:
 PSYCHOSIS (COMMAND
AHS); AFFECTIVE
DISORDERS; PERSONALITY
VULNERABILITIES;
SUBSTANCE INTOXICATION
OR WITHDRAWAL
 MANAGEMENTS
 CLARIFY THREAT TO OTHER(S)
 IF THREAT IS DEEMED SERIOUS
 NOTIFY POLICE
 MAKE EFFORTS TO WARN
INDIVIDUAL(S) (TARASOFF
RULING)
 ADMIT PT UNTIL THREAT
SUBSIDES
 DON’T HESITATE TO ADMIT
INVOLUNTARILY EVEN IF PRECISE
PSYCHIATRIC DIAGNOSIS REMAINS
ELUSIVE IN THE END

53. AGITATED DELIRIUM
 FLUCTUATING SENSORIUM
 SUICIDAL AND HOMICIDAL
RISK
 COGNITIVE CLOUDING
 VISUAL, TACTILE, AND
AUDITORY HALLUCINATIONS
 PARANOIA
 EVALUATE ALL POTENTIAL
CONTRIBUTING FACTORS AND
TREAT EACH ACCORDINGLY
 REASSURANCE, STRUCTURE,
CLUES TO ORIENTATION
 BENZODIAZEPINES
 HIGH-POTENCY
ANTIPSYCHOTICS MUST BE
USED WITH EXTREME CARE
BECAUSE OF THEIR POTENTIAL
TO ACT PARADOXICALLY AND
INCREASE AGITATION

54. ALCOHOL DEPENDENCE AND
DELIRIUM
 CONFUSION,
DISORIENTATION,
FLUCTUATING
CONSCIOUSNESS AND
PERCEPTION, AUTONOMIC
HYPERACTIVITY; MAY BE
FATAL
 BDZ
 THIAMINE
 MET
 ANTICRAVING

55. GERIATRIC BEHAVIORAL PROBLEMS
 DISTRESS AND PAIN MAY BE
CAUSED BY:
 EXPOSURE TO NEW
EXPERIENCES
 ALTERATIONS TO
ROUTINES
 ANXIETY AND DEPRESSION
ARE TOO OFTEN
CONSIDERED A “NORMAL
PART OF AGING.”
 AGEISM:
DISCRIMINATION
AGAINST OLDER PEOPLE

56. PEDIATRIC BEHAVIORAL PROBLEMS
 50% OF CHILDHOOD
MENTAL ILLNESSES WILL
PRESENT BY AGE 14
YEARS.
 MORE LIKELY TO HAVE
COEXISTING PROBLEMS
 DIFFICULT TO DIAGNOSE
 MENTAL STATUS
ASSESSMENT IS SIMILAR TO
THAT OF AN ADULT.
 EXCEPTION: CONSIDER
DEVELOPMENTAL LEVEL.
 ABNORMAL FINDINGS ARE
OFTEN RELATED TO
ADJUSTMENT DISORDERS
AND STRESS.

57. MANAGEMENT
 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
 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.

58. ABUSE OF CHILD OR ADULT
 SIGNS OF PHYSICAL
TRAUMA
 MANAGEMENT OF
MEDICAL PROBLEMS

59. ADOLESCENT CRISES
 SUICIDAL ATTEMPTS AND
IDEATION
 SUBSTANCE ABUSE
 TRUANCY, TROUBLE WITH
LAW
 PREGNANCY
 RUNNING AWAY
 EATING DISORDERS
 PSYCHOSIS
 EVALUATION OF SUICIDAL
POTENTIAL
 EXTENT OF SUBSTANCE
ABUSE
 FAMILY DYNAMICS
 CRISIS-ORIENTED
FAMILY AND INDIVIDUAL
THERAPY
 HOSPITALIZATION IF
NECESSARY
 CONSULTATION WITH
APPROPRIATE
EXTRAFAMILIAL
AUTHORITIES

60. BORDERLINE PERSONALITY
DISORDER
 SUICIDAL IDEATION AND
GESTURES
 HOMICIDAL IDEATIONS
AND GESTURES
 SUBSTANCE ABUSE
 MICRO PSYCHOTIC
EPISODES
 BURNS, CUT MARKS ON
BODY
 SUICIDAL AND HOMICIDAL
EVALUATION (IF GREAT,
HOSPITALIZATION)
 SMALL DOSAGES OF
ANTIPSYCHOTICS
 CLEAR FOLLOW-UP PLAN

61. BRIEF PSYCHOTIC DISORDER
 EMOTIONAL TURMOIL
 EXTREME LABILITY
 ACUTELY IMPAIRED
REALITY TESTING AFTER
OBVIOUS PSYCHOSOCIAL
STRESS
 HOSPITALIZATION OFTEN
NECESSARY
 LOW DOSAGE OF
ANTIPSYCHOTICS MAY BE
NECESSARY BUT OFTEN
RESOLVES SPONTANEOUSLY

62. CATATONIC SCHIZOPHRENIA
 MARKED PSYCHOMOTOR
DISTURBANCE (EITHER
EXCITEMENT OR STUPOR)
 EXHAUSTION
 CAN BE FATAL
 RAPID TRANQUILIZATION
WITH ANTIPSYCHOTICS
 MONITOR VITAL SIGNS
 AMOBARBITAL MAY
RELEASE PATIENT FROM
CATATONIC MUTISM
STUPOR BUT CAN
PRECIPITATE VIOLENT
BEHAVIOR
 LORAZEPAM CAN BE USED

63. DELUSIONAL DISORDER
 MOST OFTEN BROUGHT IN
TO EMERGENCY ROOM
INVOLUNTARILY; THREATS
DIRECTED TOWARD OTHERS
 ANTIPSYCHOTICS IF PATIENT
WILL COMPLY (IM IF
NECESSARY)
 INTENSIVE FAMILY
INTERVENTION
 HOSPITALIZATION IF
NECESSARY

64. DEMENTIA
 UNABLE TO CARE FOR SELF
 VIOLENT OUTBURSTS
 PSYCHOSIS
 DEPRESSION AND SUICIDAL
IDEATION
 CONFUSION
 SMALL DOSAGES OF HIGH-
POTENCY ANTIPSYCHOTICS
 CLUES TO ORIENTATION
 ORGANIC EVALUATION,
INCLUDING MEDICATION
USE
 FAMILY INTERVENTION

65. DEPRESSIVE DISORDERS
 SUICIDAL IDEATION AND
ATTEMPTS
 SELF-NEGLECT
 SUBSTANCE ABUSE
 ASSESSMENT OF DANGER
TO SELF
 HOSPITALIZATION IF
NECESSARY
 NONPSYCHIATRIC CAUSES
OF DEPRESSION MUST BE
EVALUATED

66. Panic disorder
 PANIC, TERROR; ACUTE
ONSET
 MUST DIFFERENTIATE
FROM OTHER ANXIETY-
PRODUCING DISORDERS,
BOTH MEDICAL AND
PSYCHIATRIC; ECG TO RULE
OUT MITRAL VALVE
PROLAPSE
 ALPRAZOLAM (0.25 TO 2.0
MG); LONG-TERM
MANAGEMENT MAY
INCLUDE AN
ANTIDEPRESSANT

67. HOMOSEXUAL PANIC
 ADAMANTLY DENY
HAVING ANY
HOMOEROTIC IMPULSES
 AROUSED BY TALK, A
PHYSICAL OVERTURE
 PLAY AMONG SAME-SEX
FRIENDS
 PANICKED PERSON SEES
OTHERS AS SEXUALLY
INTERESTED IN HIM
 VENTILATION,
ENVIRONMENTAL
STRUCTURING
 BDZ/ ANTIPSYCHOTICS MAY
BE REQUIRED
 OPPOSITE-SEX CLINICIAN
SHOULD EVALUATE THE
PATIENT WHENEVER POSSIBLE

68. INTOXICATIONS
 ALCOHOL INTOXICATION
 ANTICHOLINERGIC
INTOXICATION
 ANTICONVULSANT
INTOXICATION
 BENZODIAZEPINE
INTOXICATION
 CAFFEINE INTOXICATION
 CANNABIS INTOXICATION
 COCAINE INTOXICATION
AND WITHDRAWAL
 L-DOPA INTOXICATION
 OPOID INTOXICATIONS
 BROMIDE INTOXICATION

69. RAPE AND SEXUAL ASSAULT
 AN UNEXPECTED AND VIOLENT THREAT ON ONE’S LIFE.
 IT IS A LOSS, VIOLATION AND INSTANT DEMORALIZATION.
 TYPICAL REACTIONS INCLUDE SHAME, HUMILIATION,
ANXIETY, CONFUSION AND OUT RAGE.

70. MANAGEMENT
1. STAY WITH THE PATIENT THE ENTIRE TIME IN THE E.R.
2.EXPLANATIONS FOR SPECIFIC DATA THAT IS NEEDED.
3. CONSENT FOR EXAMINATION AND SPECIMEN COLLECTION
4. PATIENT AND CONSIDERATE. NEVER PRESS OR HARASS THE
PATIENT FOR ANSWERS.
5.ANSWER THE PATIENT’S QUESTIONS AND FREQUENT
REASSURANCE THAT THE PATIENT IS IN A SAFE PLACE.
6.THE PATIENT MUST BE GIVEN TIME AND DATE TO MAKE HER
OWN DECISION ABOUT THE LEGAL PROCESS.

71. 7. EDUCATE THE PATIENT ABOUT THE RAPE TRAUMA
SYNDROME.
8. CALL THE PATIENT 48HOURS LATER AND THEN WEEKLY FOR
FOLLOW UP.
9. ON LATER STAGES, PROVIDE COUNSELING WITH REALISTIC
ISSUES SUCH AS WORK, HOME, LEGAL DIFFICULTIES, SHARING
OF EMOTION, FUTURE REHABILITATION.

72. CRISIS INTERVENTION
 UNEXPECTED SERIES OF EVENT
 DANGER OR OPPORTUNITY
 PHYSICAL,PSYCHOLOGICAL,INTERPERSONAL
 DEVELOPMENTAL,SITUATIONAL

73. ABC MODEL
 ACHIEVING RAPPORT
 BEGINNING OF PROBLEM IDENTIFICATION
 COPING

74. DEATH AND DYING
 DENIAL AND ISOLATION
 ANGER
 BARGAINING
 DEPRESSION
 ACCEPTANCE

75. LEGAL ISSUES IN EMERGENCY
PSYCHIATRY
 CONFIDENTIALITY
 DUTY TO WARN
 COMPETENCY
 INFORMED CONSENT
 INVOLUNTARY COMMITMENT

76.  BEHAVIORAL EMERGENCIES CAN PRESENT UNIQUE
CHALLENGES IN PATIENT MANAGEMENT. FOCUS ON
REDUCING THE PATIENT’S STRESS WITHOUT
EXPOSING OWNSELF TO UNNECESSARY RISKS.

77. OUR GREATEST WEAKNESS LIES IN GIVING UP. THE
MOST CERTAIN WAY TO SUCCEED IS ALWAYS TO TRY
JUST
ONE MORE TIME.
-THOMAS EDISON

78. REFERENCES
 Kaplan & sadock's comprehensive textbook of
psychiatry, 9th edition
 Emergency psychiatry by Hani raoul khouzam,Doris
tiu tan,Tirath sing gill

79. THANKING YOU