This document discusses psychiatric emergencies in children. It defines psychiatric emergencies as situations where there is direct and immediate threat to a child's mental health or where distressing psychiatric or behavioral symptoms require emergency attention. Common psychiatric emergencies in children include severe depression and suicide risk, dissociative disorders, anxiety, abuse, conduct disorders, and psychotic disorders. Emergent presentations can include impaired consciousness, abnormal behavior, suicidal behavior, aggression, refusal to eat, and acute anxiety. The document outlines approaches to assessment and management of such psychiatric emergencies in pediatric populations.

1. PRESENTER-
DR ANGSHUMANKALITA
DISCUSSANT-
DR NABANITA SENGUPTA
CHAIRPERSON-
ASSO PROF DR DEEPANJALI MEDHI
PSYCHIATRIC EMEGENCIES IN CHILDREN

2. INTRODUCTION
Definition:
A psychiatric emergency is any disturbance in thoughts,
feelings or actions for which immediate therapeutic
intervention is necessary.

3. Definition:
Psychiatric emergencies in children are those clinical
situations where there is direct & immediate threat to the
mental health of the child with or without physical harm
or where the child exhibits such distressing or disruptive
psychiatric or behavioral symptoms that need emergency
attention

4. HISTORY
 Originated in Russo-Japanese War (1904-1905)
 Psychiatrist in the Imperial Russian Army treated psychiatric
emergency for the first time
 In 1944, US Psychiatrist introduced CRISES ORIENTED
THERAPY
 From 1950-1960,modern field of Emergency Psychiatry
developed
 1980 American Association for Emergency Psychiatry was
founded

5. In a study titled ‘Psychiatric emergencies in children’ done
by Christodulu et al it was found that during a 13 month
period , a more than 600 visits to the ED were made for mental
health concerns for children aged 2-18 yrs. Psychiatric visits
constituted more than 5% of total visits
In another study titled ‘Epidemiology of psychiatric related
visits to emergency departments in a multicenter
collaborative research pediatric network’ done by P
Mahajan et al found that pediatric psychiatric related visits
accounted for 3.3% of al participating ED visits

6. In another study titled ‘Disproportionately Increasing
Psychiatric Visits to the Pediatric Emergency
Department Among the Underinsured,’ found that over
8 years, 279 million pediatric emergency patients were
seen in US EDs, of which 2.8% were psychiatric visits.
The prevalence increased from 2.4% in 1993 to 3% in
2007.

7. WHO NEEDS EMERGENCY CARE?
Healthy children- faced with adverse & sudden significant
life events, e.g. crisis, disaster, bereavement, break down of
family or child abuse; presents with serious disturbances in
emotion, behavior or adjustment
Clear psychiatric disorders- acute psychotic breakdown,
anorexia nervosa, severe depression, conduct disorder which
may be so disruptive/ distressing to child/family/society that
immediate control is necessary
Admitted children-Sometimes these emergencies arise for
admitted children receiving inpatient treatment for medico-
surgical illness where psychiatric help is sought.

8. SPECIAL ISSUES
Since most children & adolescents are basically
dependant on their parents, it is they & not the children
themselves who perceive the situation as an emergency &
seek help
Occasionally older children or adolescents, or school-age
children may directly report for help. It happens when
they come from non-supportive environment or home

9. Apart from parents, it may sometimes be teachers,
pediatricians & rarely police or other social agencies may
refer the child for emergency care
Depending upon the availability of services most of the
cases present to general medical ER or pediatric or
psychiatric departments.

10. Most emergencies occur within the family or the school
setting
Often give warning signals before becoming emergent
Many a times, it is a chronic lingering maladjustment or
disturbance that assumes such a proportion so as to be
called as emergency, e.g. parental discord, anxiety,
maladjustment in school etc.

11. APPROACH TO EMERGENCY PSYCHIATRIC
DIAGNOSIS
 Psychiatrist must perform rapid assessment with the goal of developing an
immediate treatment plan that will ensure safety of the patient and others
 FIRST PRIORITY:
 “ Primum non nocere”: above all, do not harm- always ensure safety of all
 SECOND PRIORITY:
 Rule out medical etiology
 Detailed informative history.
 Assessment of seriousness
 Stabilization of the patient if required
 Physical examination including relevant lab. investigations.
 Thorough mental status examination.
 Developing a differential diagnosis
 THIRD PRIORITY:
 Appropriate treatment and disposition

13. DISORDERS THAT ARE LIKEKY TO PRESENT
AS EMERGENCIES
1. Severe depression & suicide
2. Dissociative disorders
3. Anxiety & panic disorder
4. Child abuse
5. Conduct disorders
6. Post-traumatic stress disorders
7. Drug abuse
8. Anorexia nervosa
9. Psychotic disorders

14. CLINICAL MANIFESTATIONS
Irrespective of the diagnosis, these disorders may present as any
of the following emergent clinical problems:
I. Fits or impaired consciousness
II. Abnormal behavior
III. Suicidal behavior, e.g. bodily harm, poisoning, drug overdose
IV. Aggression & violence
V. Paralysis, paresis, loss of bodily sensations
VI. Refusal to eat & severe weight loss
VII. Hyperventilation
VIII. Acute anxiety & panic
IX. Acute pain
X. Non- accidental injuries & neglect

15. These presenting symptoms do not necessarily
corresponds to a specific psychiatric diagnosis. These are
symptoms of child’s distress or disease.
Clinical evaluation addresses not merely a diagnosis in the
child but also evaluates the parents & the psychosocial
situation
For effective intervention, management of
psychopathology in the parents & the general/specific life
of the child must also be attempted.

16. FITS OR IMPAIRED CONSCIOUSNESS
One of the common & most dramatic presentations
in ER
C/c- “Fits”
Ch by-symptoms of impaired consciousness,
abnormal movement or behavior
Episodic disturbance, lasting few min to hours

17. Often interspersed with periods of recovery
Consciousness-impaired, not totally lost; may show
response to deep painful stimuli
Memory- partial or full preservation of memory

18. Dissociative disorder:
Present as trance like states
Do not remember chunk of their behavior
May even exhibit psychotic phenomenon-visual/auditory
hallucinations, feeling of being controlled by external forces
These used to occur in children who have experienced acute or
chronic stress or abuse of a severe degree.
Children when overwhelmed by stress or when they feel
caught in an inescapable traumatic situation spontaneously
drift into dissociative states.

19. Management:
Since dissociative disorder occurs in the setting of hostile,
threatening & abusive environment; the clinician must
determine whether the child is still under danger or threat
& he/she needs to be protected from the environment.
If the symptoms are severe & disruptive, hospitalization is
necessary

20. Immediate relief from symptoms can be obtained by
providing a reassuring nonthreatening & protective
environment, isolation, establishing communication with
the child & encouraging him/her to express feelings which
generally are of anxiety, fear, anger or unhappiness
Rapport establishment is very important
Drugs have no role. If there is high evidence of anxiety
then anxiolytics can be given

21. Apart from environmental intervention, such a child is
treated with a variety of psychotherapeutic methods
including play therapy & behavior therapy
Reassurance & explanation to family members is crucial
Parents need to be informed about the psychological
nature of the illness in such a manner that they understand
the problem in the right perspective

22. SUICIDAL BEHAVIOUR
One of the common reasons
Most children under 12 years of age who threaten or
attempt suicide may not kill themselves.
It may present in the form of bodily harm (wrist slashing),
poisoning, drug overdose rarely more violent means like
hanging, gunshot may be employed

23. A sad generation?
 Suicide is the third leading cause of death in the 15-24
age group (follows unintentional injuries & homicide)
Male gender, drug abuse, conduct disorder.
For every complete suicide, there may be 50 – 200
attempts with a female preponderance.

24. Risk factors
Loss of parent before the age of 12
History of parental abuse
Early onset of suicidal behavior (prepubertal) predicts
suicidal behavior in adolescents
More than 90% of subjects who committed suicide met
criteria for at least one major psychiatric diagnosis
Half of these subjects had psychiatric disorder for at least
two years

25. Acute psychosocial stress
One in four adolescents that completed suicides show evidence
of planning
The most common diagnostic groups were mood disorders
(52% major depression), disruptive disorders and substance
abuse
A child with a mood disorder is four to five times more likely
to attempt suicide than a child without a mood disorder

26. NON SUICIDAL SELF INJURY NSSI

27. Non-suicidal self-injury is the direct, deliberate
destruction of one’s own body tissue in the absence of
intent to die.
 It differs from suicide attempt with respect to intent,
lethality, chronicity, methods, cognitions, reactions,
aftermath, demographics and prevalence.
Common forms of NSSI include cutting, burning,
scratching, banging, hitting, biting and excessive rubbing.

28. Preceding the act of self-injury is a psychological
experience of increasing anger, tension, anxiety, dysphoria
and general distress or depersonalisation, which the
person feels they cannot escape from or control.
Engaging in NSSI provides a temporary release from
these distressing emotions.

29. Prevalence
Most studies found prevalence ranging from 15 to 25% in
young adults and adolescents.
Along with BPD, seen in patients with mood and anxiety
disorders, eating disorders, substance misuse, conduct
disorder and post-traumatic stress disorder.

30. NSSI and Suicidality
NSSI is the strongest predictor of future suicide attempts
in adolescents
High levels of depression, suicidal ideation and
hopelessness characterise participants who engage in
either NSSI or suicide attempt.

31.  Assessment must refer to the totality of the event &
circumstances surrounding the act-severity & persistence
of suicidal ideation or intent, lethality, underlying
depression or conduct disorder, drug abuse, prior suicidal
attempt, f/h of suicide, access to weapons etc
 Detailed psychiatric history, MSE & assessment of family
functioning must be done

32. Management
 Hospitalization- initially in medical/surgical unit.
 Psychiatric hospitalization-high risk for suicide, evidence
of psychosis & depression, persistence suicidal ideation,
prior suicidal attempt, chaotic or dysfunctional family
 High surveillance for repeated attempt must be
maintained for a few days after the current attempt
 Medication for primary psychiatric disorder if present in
the child

33. Characteristics of psychiatric units
 Ground floor
 Easily observable rooms.
 Weapons, toxic substances, electrical devices- made out of
reach for patients.
 Hanging- 10% occur in hospitals. Restrict access to means
of hanging.
 Unfortunately, suicides still may occur unexpectedly.

34. AGGRESSIVE & VIOLENT BEHAVIOUR
 May be a manifestation of underlying psychotic disorder like
schizophrenia or BPAD, ADHD, delirium or seizures.
 May be a reaction to interpersonal difficulties with parents,
peers or teachers
 Children or adolescent who have low frustration tolerance,
poor impulse control, underlying personality difficulties of
borderline or antisocial type, conduct disorder,
oppositional defiant disorder or drug abuse, etc. might
show aggression or violence

35.  The first task in such an emergency is to assess the risk & safety of
the child & of those around him
 Do’s
1. Protect yourself
2. Unarm the patient
3. Keep the doors open
4. Keep others near you
5. Do restrain if necessary
6. Wear white coat & ID tag
7. Assert authority
8. Show concern, empathy, establish rapport & assure the patient
9. Encourage him/her to speak about his anxiety & minimize fear &
make him/her calm

36. Don’ts
1. Do not keep any potential weapon near the patient
2. Do not sit with back to patient
3. Do not wear neck tie or jewellery
4. Do not keep any provocative family member or friend
near the patient
5. Do not confront
6. Do not sit close to the patient

37.  During this process, a quick MSE should be done
specially looking for signs of major psychiatric illness.
 Presence of abnormal speech, irrelevant talk, delusion,
hallucination-psychosis
 Gross disorientation to time, place, memory impairment,
gross incoherence of speech, confusion, ill organized acts
of violence, sphincter incontinence- CNS pathology

38. Management:
1. Physical restraint, if necessary
2. Oral or may be parenteral ( if uncooperative) medication
in form of IM or IV inj haloperidol, chlorpromazine or
lorazepam is recommended for quick relief
3. Hospitalization- to tide over the crisis

39.  Methods of physical restraint
1. Use judiciously for the minimum period of time
2. Explain to the patient the reason for restraint
3. Should be done by trained personnel
4. Use leather restraint- safest & surest. Soft cotton cloths, if
available
5. At lest five persons are usually required to restraint
6. Restraint is done one limb at a time, while the other limbs
are held firmly by others
7. Restraint in arms are placed in such a way that IM or IV inj
or fluid can be given easily

40. 8. Patient should be restrained with legs spread eagled & one
arm restrained to one side & other arm restrained over
patient’s head
9. Head is raised slightly
10. Intoxicated patient should be restraint in the left lateral
position
11. A staff member should always be visible & reassuring the
patient.
12. Assess periodically about removal of restraint
13. Remove restraint one limb at a time
14. Vitals should be monitored periodically
15. Maintain documentation: Reason, treatment, response

41. SECLUSION
 INDICATION
Therapeutic isolation for limiting provocative
environmental stimulation (Agitated patient) e.g.
partitioned area, unlocked time out room
 CONTRAINDICATION
Patient with suicidal risk, MR, seizure disorder, drug
overdose, delirium, demented, psychosis

42. Seclusion cell in LGBRIMH,Tezpur
(NOT practised now a days)

43.  In certain situations where aggression & violence has
occurred d/t conflict between child & parent, a gentle &
calm approach, allowing the child to talk about his
difficulties brings down the aggression & medication is
not needed.
 Assessment is also made of the degree to which the child
appears or feels in control of his emotion & behavior.
 Many children can say that they are feeling alright & can
control themselves.

44.  They can be handled psychologically where a
communication is established with a therapist & an
understanding is reached to resolve the issues during
therapy sessions
 This emergency management must be followed by longer
term treatment with a psychiatrist

45. ABNORMAL BEHAVIOUR
Sudden appearance of abnormal behavior
psychomotor excitement
Stupor
irrelevant speech
abnormal motor movements
inappropriate acts
amnesias ( partial or total loss of memory)
occurring in the background of a psychiatric disorder or
emotional stress constitutes an emergency.

46. Management:
 Level of consciousness must be ascertained
 Neurological assessment must be done- to r/o neurological
causes
 Sudden abnormal behavior can occur in acute onset functional
psychosis, e.g. schizophrenia, affective disorder or acute &
transient psychotic disorder. In these cases delusion,
hallucination, gross psychomotor excitement, stupor etc. may
be present

47.  Often schizophrenia & affective disorders takes days or
weeks to develop. In some cases the onset of psychosis
may be abrupt particularly when there is acute stress
preceding the onset & in such cases psychosis is brief &
short lasting
 Sometimes drug intoxication or withdrawal might present
as acute psychosis
 Detailed history is sufficient to clarify the diagnosis

48.  Sometimes abnormal behavior is not of psychotic
proportions or there are no psychotic symptoms. It can
occur following acute emotional stress as in dissociative
disorder or PTSD
 Such a child is handled with psychological support in the
form of reassurance, ventilation & catharsis,
encouragement & positive guidance.
 Change in the environmental circumstances like removal
of the child from stress situation may be necessary
sometimes.

49.  Medication may be given as necessary to counteract
manifest anxiety or depression or psychotic behavior
 Patient who shows continuous or recurrent abnormal
behavior need to be admitted

50. REFUSAL TO EAT & SEVERE WEIGHT
LOSS
 Rare, but life threatening emergencies
 Usually encountered in adolescent females.
 Anorexia nervosa - refusal to eat, anorexia & persistent
vomiting, wt. loss

51.  Patients go into a medical emergency due to
complications of starvation:
1. Dehydration
2. Dyselectrolytemia
3. Hypoglycemia
4. Cardiac arrhythmia
5. Vomiting
6. Abdominal pain
 Mortality in severe cases is 15-20%

52.  Bulimia nervosa- Sometimes patients goes into bouts of
overeating followed by extreme steps to control body
weight like vomiting (often induced), purging, starvation,
use of drugs, etc.
 It may also present with Dyselectrolytemia, muscle
weakness, seizure etc.

53. Management:
Hospitalization
Immediate assessment of the functioning of vital organs like-
ECG, CBC, S. electrolytes, RFT, LFT, urinanalysis
Often highly resistant to treatment & may have to be admitted
against patient’s wish
Any serious medical complication to be managed accordingly

54.  Psychological assessment& psychiatric evaluation
 Family members are explained the seriousness of the
disease
 Further treatment in the form of intensive psychotherapy,
behavior therapy, family therapy is carried out in
psychiatric ward or OPD

55. PARALYSIS, PARESIS, LOSS of BODILY
SENSATIONS
Sometimes patients are brought to emergency with sudden
development of weakness of limbs or paralysis or loss of
superficial sensations (pain, touch, temperature) or of special
sensations like loss of vision, hearing, smell or taste
More dramatic presentations like aphonia, mutism,
Agraphia, paraesthesias, etc. are not uncommon.
These symptoms can be easily distinguished from true
neurological symptoms on the basis of a good history &
clinical examination

56. Points against a diagnosis of neurological disorder
( points in favour of a diagnosis of dissociative
disorder):
1. Sudden development of these symptoms in absence of
any h/o medical/neurological illness preceding it
2. Without any evidence of concomitant disease
3. Symptoms do not follow the known pattern of
distribution, based on anatomical & functional
segments of the CNS

57. 4. Occurs following a stressful event
5. Disability & distress is disproportionately lower than
the severity of symptoms
6. Functions underlying the symptoms is preserved
which can be demonstrated by encouraging the child,
giving positive suggestions or by sudden maneuver
when the child is inattentive

58.  These symptoms are often constructed as child’s cry for
help in a situation of emotional trauma or stress which the
child is trying to avoid or resolve.
 Seen in children who have relatively low IQ & who
come from lower SES families who have limited
resource & are unable to handle their life problems in a
more adaptive manner

59. Management:
 It should be cautious & sensitive
 Should not be understood as feigning or malingering as
they are troubled by emotional difficulties
 Approach should be empathic & supportive-to bring out
the underlying cause of emotional distress

60.  Ideally they should be interviewed alone
 Reassurance & positive suggestions, encouragement can
be used to make the symptoms disappear
 Once the symptom is removed the family feels reassured

61.  Family members are explained the nature of illness. The
genuineness of patient’s symptoms should be emphasized
 Parents are explained the need for establishing a
communication with the child where the child can express
his desires & needs without fear.
 They should understand the child’s emotion & their
thoughts need to be respected & duly considered

62.  Further treatment should target at resolution of conflicts,
improvement in interpersonal relationships, developing
alternate & more adaptive ways of handling stress
 Drugs have no role, but can be used as placebo for quick
removal of symptoms
 Main mode of treatment is psychotherapy

63. ACUTE ANXIETY & PANIC
Acute anxiety can occur in many psychiatric disorders & may manifest as
 Acute palpitation
 sweating,
 Trembling
 Chocking
 Dizziness
 Numbness
 Tingling
 Hyperventilation
 Fainting
 Acute chest pain
All these symptoms may build up gradually or may start suddenly & remain
for a variable period of time

64. In children panic attack can occur as a manifestation of
separation anxiety (separation from parent figure), school
phobia or sexual abuse
Sometimes symptoms like Derealization or
depersonalization, fear of dying, light headedness,
unsteadiness, nausea or abdominal distress may also be seen
All these symptoms pertaining to emotional, cognitive &
somatic domains characterize underlying anxiety which when
acute & intense may be brought to ED

65. PTSD
Children who have experienced severe catastrophic
traumatic events may develop extreme fear of the specific
trauma or of the situations or persons associated with the
traumatic event
Child may be terrified, hallucinate, re-live traumatic
situations, have illusions or dreams about it
 It can be easily recognized by h/o trauma & the
characteristic symptoms reflecting the trauma

66. Separation anxiety
Common in young children
Join school first time or separated from attachment figures
usually mothers
Extreme fear or worry about well being attachment figure
Headache, stomachache, nausea, vomiting
When first seen in adolescence it indicates presence of
depressive & anxiety disorder or psychosis

67. Management:
 Rule out presence of any underlying medical illness
Child should be placed in a calm, comfortable non
threatening environment & reassured
Ask to take regular, slow & deep breathes
For quick relief anxiolytics can be prescribed

68. Family should be reassured
In some cases hospitalization may be necessary
Supportive psychotherapy, behavior therapy & play
therapy are very useful
In separation anxiety & PTSD- sertraline can be added to
psychotherapy

69. ACUTE PAIN
What is pain?
Pain is subjective feeling of an unpleasant sensation that
underlies a physical disease with an associated emotional
upset
Very common presentation in ED
To differentiate between somatic pain & psychogenic pain
a thorough physical exam & clinical history should be
taken in every case

70. Psychogenic pain is often variable & shifting in nature &
is modified by situational stress & distraction
A sudden, dramatic onset of pain in absence of a
known h/o physical disorder, occurring in stressful
situation or in the background of dissociative disorder,
anxiety, depression & histrionic behavior is likely to be
a psychogenic pain

71. Emergency Management:
 Not relieved by NSAIDS
 May respond to narcotic analgesic & TCAs
 Anxiolytics are not effective

72. Long term treatment:
Psychotherapy
Medication-SSRI
Effort should be made to understand the meaning of pain
for patient in the background of his/her emotional upsets
& life circumstances
If there is evidence of underlying anxiety, depression,
hypochondriasis, etc. then it should be treated by
psychiatrist

73. If pain is manifesting only as a stress response, then stress
should be managed.
Help to acquire greater skill to handle emotions or life
stress
Biofeedback, yoga, meditation

74. NON-ACCIDENTAL INJURIES
It includes child abuse- a state of emotional, physical,
economic and sexual maltreatment meted out to a person
below the age of eighteen
There is a section of children who are more vulnerable for
child abuse. They are 1) children who grew up in very poor
family, 2) children with divorced parents, 3) children with
highly stressed caregiver, 4) differently abled children.
 There are four major categories of child abuse: Physical
abuse, Psychological/emotional abuse, Sexual abuse &
Neglect

75. Physical abuse included injuries like cuts, bruises,
multiple fractures, burns
One should suspect sexual abuse in a child when the child
is having difficulty in walking or sitting,stained or bloody
underwear or whent here is pain, itching, redness,
discharge,bruise or other injuries in private parts.

76. One should suspect emotional abuse in a child when he
or she appears to be extremely aggrssive
Neglect is another type of child abuse. It should be
suspected when there is lack of basic food and clothing,
inappropriate child hygiene ,lack of appropriate
supervision,lack of education,lack of medical treatment
or medication for a serious illness or residing in an
inappropriate/dangerous living environment . These
children may have delayed growth and developement. In
infants it can present as failure to thrive.

77. These children are brought with complaints of physical
injury or damage that does not fit the history or details of
the accident given by attendants.
Abuse is suspected by the clinician

78. Munchausen syndrome by proxy:
 Mother induces or fabricates the illness in the child,
brings him over to the doctor repeatedly
May present with many serious & sinister symptoms like
poisoning, seizures, bleeding from various orifices, fever,
injuries etc. (Meadow 1989)

79. For diagnosis it is necessary to have high degree of
suspicion.
Indications pointing towards non-accidental injuries:
1. Delay in seeking medical help
2. History & clinical examination does not add up
3. Inadequate concern or anxiety toward the child
4. Child may appear frightened of his attendants,
withdrawn

80. 5. Hostility or anger towards the child & doctor
6. Not allowing the doctor to directly talk with the child
7. Rejecting or refusing treatment
8. DAMA/LAMA

81. Perpetrators of abuse can be biological parents, step
parents or caregivers
Emotional & sexual abuse is more common than physical
abuse
May be acute/ chronic abuse

82. Management:
 If suspicion?
interview the child & the family members individually
Close observation of child’s behavior, parent-child
relationship
In all cases child’s safety & protection are foremost
concern

83. For child’s protection social & legal agencies need to be
involved
Give strong reassurance & support to the child
Further psychiatric intervention involves improving the
parent-child relationship, improving parenting skills &
attitude of parents; help to control impulses; problem
solving skills

84. The Protection of Children from Sexual
Offences (POCSO) Act,2012
 Provides protection from sexual assault, sexual harassment and
pornography
 Section 21 of the Act, requires mandatory reporting of cases of
child sexual abuse, hence the onus is on citizens, that is parents,
doctors and school personnel to report cases to the law enforcement
authorities (Special Judicial Police Unit or Local Police).
 Failure to report a suspicion of child abuse punishable with
imprisonment of six months or with fine or both. Those running
institutions have greater punishment which may extend to one year
or with fine or both.
 This provision also focuses on police personnel who refuse to
register child abuse cases.

85. INHALANT RELATED DISORDER
Intoxication-
ch by apathy, diminished social & occupational functioning,
impaired judgment, impulsive or aggressive behavior often
accompanied by nausea, anorexia, nystagmus, diminished
reflexes & diplopia.
Patient may also come in stuporous & unconscious state or
amnesia for a brief period
Clinician can sometime identify a recent user by rashes round
nose & mouth, unusual breath odor, residue of the substance in
body & cloths, irritation in eyes, throat, lungs & nose

86. Management:
 Often resolves spontaneously
 Treat if there is any coma, bronchospasm, laryngospasm,
cardiac arrhythmia, trauma or burns.
 Sedative drugs are contraindicated
 Primary care- reassurance, support, attention to vitals &
consciousness
 Street outreach & extensive social service support, family
support is necessary

87. RECOMMENDED DRUGS FOR RAPID
TRANQUILISATION
MEDICATION DOSE ONSET OF ACTION
Olanzapine, IM 2.5-10 mg 15-30 min IM
Haloperidol 0.025-0.075mg/kg/dose
(max 2.5mg) IM
>12 yrs 2.5-5mg
20-30 min IM
Lorazepam 0.05-0.1 mg/kg/dose IM 20-40 min
Midazolam 0.1- 0.15 mg/kg 10-20 min IM
1-3 min IV
Diazepam, IV 0.1 mg/kg/dose slow IV
Max 40 mg total <12 yrs
60 mg>12 yrs
1-3 min
Ziprasidone 10-20 mg 15-30 min IM

88. DRUG TREATMENT OF PSYCHOSIS
First choice Allow patient to chose from
Aripiprazole ( to 10 mg)/
Olanzapine ( to 10 mg)/
Risperidone (to 3 mg)
Second choice Switch to alternate drug
Third choice Clozapine

89. DRUG TREATMENT FOR BPAD
DRUG DOSE
Aripiprazole 10 mg daily
Olanzapine 5-20 mg daily
Quetiapine 400 mg daily
Risperidone 0.5-2.5 mg daily
Valproate Titrate to above 50 mg/l

90. DRUG FOR DEPRESSION
Fluoxetine is the 1st line pharmacological treatment
Start with a low dose of 10 mg daily

91. CONCLUSION
 Psychiatric & behavioral emergencies could pose an
immediate threat to child’s life or it could be non
threatening.
In all the situations, an emergency is an indication of the
breakdown of an already compromised psychological,
social & family functioning.
It also serves as the contact point for initiation of steps for
remedy & restoration of dysfunction.

92.  A comprehensive assessment of the biological,
physical, psychosocial & family factors is necessary.
Simple supportive measures like ventilation,
catharsis, reassurance & expression of regard for the
patient is very helpful

93. Drugs have a very limited role accept for the treatment of
medical complications or in cases of severe psychiatric
illness like psychosis, depression or anxiety
Psychiatric hospitalization may be necessary to tide over
the crisis.
Psychiatric consultation in emergency sets the tone for
subsequent prolonged intervention for the treatment of the
basic pathology

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