Psychiatric emergencies are acute changes in behavior that negatively impact a patient's ability to function in his or her environment. ... The screening assessment also involves a psychiatric safety check to explore for suicidal ideation, homicidal ideation, or patients' inability to care for themselves.

1. PSYCHIATRIC EMERGENCIES
Presented by: Ms Ritika soni

2. Objectives
At the end of the class the students are able to
• Define Psychiatric emergencies
• Enlist the types of psychiatric emergencies
• Enumerate etiology of psychiatric emergencies
• Explain the management of different types of
psychiatric emergencies

3. Emergency
• It is defined as an unforeseen combination of
circumstances which calls for an immediate action.
• Medical emergency: it is defined as a medical
condition which endangers life or causes great
suffering to the Individual.

4. Psychiatric Emergencies
• A condition where the patient has disturbances of
thought, affect and psychomotor activity which
causes sudden distress to the individual or sudden
disability, thus requiring immediate management.
• Needs immediate intervention
– To safeguard the life of pt. & others
– Reduce anxiety of family members
– to enhance emotional security to others in the
environment

5. Types of Psychiatric Emergencies
1. Suicidal threat/ attempt
2. Violent/Aggressive behaviour
3. Panic Attacks
4. Hysterical Attacks
5. Transient Situational Disturbances
6. Epileptic Furor
7. Drug Toxicity
8. Victims of disaster
9. Rape victim
10. Catatonic Stupor
11. Delirium Tremens
12. Acute Drug-induced EPS

6. SUICIDAL THREAT/ ATTEMPT
• Commonest emergency in psychiatry's.
• Commonest cause of death among psychiatric patient
• Deliberate self harm(DSH)
• Defined as intentional human act of killing oneself OR Self inflicted
cessation(death). It ends with fatal outcomes.
• Attempted suicide: is an unsuccessful suicidal act with non-fatal outcome.
• Believed that 2-10% of all persons who attempt suicide, eventually complete
suicide in next 10 years.
• Suicidal gesture: (suggesting a cry for help) , is an attempted suicide where the
person performing the action never intends to die by the act.
• Crime by law
Etiology
• Psychiatric disorders – major depression, schizophrenia, drug & alcohol abuse,
dementia, delirium, personality disorder
• Physical disorders – incurable, painful physical conditions like cancer, AIDS
etc.
• Psychosocial factors – Failures, losses, dowry harassment, marital problems,
isolation & alienation from social groups, financial & occupational difficulties

7. • Psychological theory:
Acc to Freud:
• Anger turned inward
• Hopelessness
• Desperation & guilt
• h/o aggression and violence
• Shame & humiliation
• Developmental stressor-conflict, separation, rejection, economic problems, medical illness.
• Socio-logical theory:
Acc to Durkheim : three categories
1) Egoistic suicide : individual who feels separate &apart from the main stream of society.
integration is lacking. Individual doesn't feel a part of group.
2). Altruistic suicide: is opposite of egoistic suicide. Individual is excessively integrated to
society/ in to the group.
3). Anomic suicide: occurs in response to changes that occur in an individual’s life (eg.
Divorce, loss of job) that disrupt feelings of relatedness to the group.
• Biological theories:
1) Genetics
2) Neurochemical factors- decreased serotonin

8. Risk Factors
• Males > 40 years of age
• Females > 55 yrs
• Men > women
• Men – greater risk of completed suicide
• Women – greater risk of attempted suicide
• H/o suicide attempts
• Recent losses
• Social isolation
• Suicidal pre-occupation (suicide note)
• Alcohol or drug dependence.
• Marital status: single person is twice. Divorced, separated, or
widowed person have 4-5 times greater risk than married.
• Highest & lowest social classes have higher suicide rates.
• Ethnicity: whites are at highest risk for suicide .

9. Methods used
• Acc to ( NCRB 2003),COMMONEST MODES ARE:
• Ingestion of poison (38.4%)
• Hanging( 29.4%)
• Burning ( 11%)
• Drowning( 9%)
• Jumping in front of train or another vehicle (3%)
• Men are using more violent methods for suicide as
compared with women.

10. Management
• Beware of –
– Suicidal threats
– Writing farewell letters
– Giving away treasured articles
– Closing bank accounts
– Appearing peaceful and happy after a period of
depression
– Refusing to eat or drink, maintain personal
hygiene

11. Management
• Monitor for –
– Take threats & attempts seriously & notify psychiatrist
– Store drugs out of reach of pt
– Remove sharp objects from pt.’s environment
– Remove straps & clothing that can be used for
strangulation
– No door bolts from inside for pt.
– Somebody to accompany pt. to bathroom
– Constant observation – never leave alone
– Good vigilance – specially during morning hrs
– Spend time with pt, talk to pt and encourage to ventilate
feelings

12. – Encourage him to talk about suicidal plans/
methods
– Sedation in cases of severe suicidal tendencies
– Encourage verbal communication about suicidal
thoughts, fear & depressive thoughts
– Enhance self-esteem by focusing on strengths
– Positive feedback, realistic praise and appreciation
for change to be given

13. Steps for preventing suicide
• Take all the suicidal threats, gestures, /attempts seriously and notify a psychiatrist
or a mental health professional.
• Psychiatrist should quantify the seriousness of the situation & take remedial
precautionary measures.
- inspect physical surroundings & remove all means of committing suicide like
sharp objects, ropes, drugs, firearms etc. search the patient thoroughly.
- surveillance, depending upon the severity of risk.
• Acute psychiatric emergency interview
• Counseling & guidance – to deal with the desire to attempt suicide, to deal with
ongoing life stressors, & teaching coping skills & interpersonal skills.
• Treatment of the psychiatric disorder with medication, psychotherapy/ECT.
• Follow up care is very important to prevent future suicidal attempts or suicide.

14. Management of attempted suicide
• Hospitalize the patient.
• Record vital signs
• Life saving measures depending on the physical condition of
the patient.
• Prevent regurgitation
• Start IV line
• Manage the shock
• Address medico-legal issues
• Discuss with other staff & reassure them
• Care of other pts – shift them away, engage in games or
recreational activities, serve food, medication earlier than
schedule, observe for any change in behaviour & report
promptly

15. 2. Violent/Aggressive behavior
• this is severe form of aggressiveness, pt is irrational, uncooperative,
delusional and assaultive.
• Violence and assaultive behavior are difficult to predict .The best
predictors of potential violent behavior are:1) excessive alcohol
intake 2) a h/o violent acts with arrests or criminal activity 3) h/o
childhood abuse.
 Signs of impending violence:
- Recent acts of violence, including property violence, verbal or
physical threats.
- Carrying weapons or others used as a weapon( forks)
- Progressive psychomotor agitation
- Alcohol or substance intoxication
- Paranoid features in a psychotic patient
- Command violent auditory hallucinations
- Brain diseases
- Catatonic excitement, certain manic episodes etc.

16. Etiology
• Organic psychiatric disorders – delirium,
dementia, psychosis in alcoholism
• Other psychiatric disorders – schizophrenia,
mania, agitated depression, substance
withdrawal, panic disorder & personality
disorder, neurotic disorders, impulsive violent
behavior- borderline personality disorder.

17. Management
Assess the risk for violence:
- Consider violent ideation, wish, intention, plan, implementation of
plan.
- Consider demographics- gender (male), age (15-24), socioeconomic
status(low), social support (few).
- Consider the patient’s history: violence, non-violent antisocial acts,
impulse dyscontrol (gambling, substance abuse, suicide, psychosis)
- Consider overt stressors ( marital conflicts, real or other loss).
- Management
• Hospitalize the pt.
• Reassurance-trustworthy relationship with patient.
• Remove the ties – a large amt of aggression is diffused by allowing freedom
– feels less humiliated
• Talk down – be firm but kind
• Chemical restraints – sedation(diazepam- 5-10 mg IV Slowly, lorazepam 1-2
mg IV slowly).
• Collect history from relatives, rule out organic pathology – H/o convulsions,
fever, recent intake of alcohol, fluctuations of consciousness

18. • Carry out complete physical examination
• Perform routine investigations
• Look for dehydration, malnutrition
• Start IV drip
• Minimum furniture in the room
• Remove sharp objects, ropes, glass items, ties, strings, match boxes
etc. from pt’s unit
• Minimum environmental stimuli, limited visitors
• Remove hazardous objects and substances
• Be with the pt & give a sense of security to pt
• Encourage the pt ‘talk out’ aggressive feelings
• Physical restraints only on prescription( leather belts, padded
bandages ect).
• Meet nutritional and elimination needs of the pt
• Involve the patient in activities which he enjoys.
• Emphasize that he is a respected person but violence is unaccepted.

19. Guidelines for self protection
• Never be alone with the patient
• Keep a arm length distance from the pt always
• Be alert & prepared to move
• Maintain a clear exit route for both the staff & pt.
• Ensure no weapons with patient.
• If the pt. has weapon, ask him firmly to keep it on
table or floor
• Never attempt to snatch it from the patient
• Distract the pt momentarily to remove the weapon
• Give prescribed antipsychotic after physically
restraining
• Never turn back to the patient.

20. 3. Panic attack
• Severe form of acute anxiety
may lead the person to be
panic, occurs as a part of
psychotic or neurotic illness
• It is characterized by
spontaneous, episodic & intense
periods of anxiety usually lasts
for few min.
• Common Symptoms are:
• Palpitations
• Sweating,
• tremors,
• feelings of choking,
• chest pain, nausea,
• abdominal distress,
• fear of dying,
• Paresthesia( tingling sensation)
• chills or hot flushes
Management of Panic Attack
• Reassure the patient.
• Search for causes
• Diazepam 10 mg or lorazepam 2 mg to calm down

21. • Behavioral therapy
• Relaxation therapy
• Drug therapy: Phenobarbitones sodium 100 mg IM
• Aprazolam(.25-.5 mg orally), lorazepam( 1-2 mg)
• EST
• If the patient is un-cooperative, tense, fainting, act in a calm & quite manner.
• Advise patient to avoid or reduce the use of coffee, alcohol intake & smoking.
 Use of 5 R’s:
- Recognition of cause
- Relationships are identified for support & help
- Relaxation through medication, massage, breathing exercises etc.
- Removal of threat or stressors
- Re-engagement/motivation.

22. 4. Catatonic Stupor
Stupor: It is a state of diminished consciousness in which patient
remains mute & still although eyes remains open & may
follow external object. Its seen in catatonia & depression.
• Clinical syndrome are:
• Mutism, negativism, stupor, ambitendency, echolalia, echopraxia, automatic
obedience, posturing, mannerism, stereotypes, etc.
Management of Catatonic stupor
• Ensure patent airway
• Administer IV fluids
• Collect history & perform physical examination, neurological exmn, to exclude
intracranial cause. E.g. Brain hemorrhage.
• Routine investigations
• Check cardiac functions
• Give attention to bowel, bladder, oral cavity, bed sores.
• Minimum dose of antidepressants
• Provide calm & secure environment
• Prepare the patient for ECT if require
• Observe the records & vital signs of the patient
• Care of the unconscious patients

23. 5. Hysterical Attack
Hysteria: attention seeking behavior, repressed anxiety,
transformation of an unconscious conflict in to physical
symptoms, such as paralysis, blindness, loss of sensation ect.
Common modes of present action are:
• Hysterical fits, hysterical ataxia(loss of control over bodily movements), hysterical
paraplegia( all or part of the trunk, legs, pelvic organ)
• Marked by dramatic quality & sadness of mood
Management
• Hysterical fits are distinguish from true / genuine fits
• Explain the psychological nature of disease to the relatives of the patient
• Reassure the family members that no harm would come to pt.
• Help the pt to recognize the meaning of symptoms & identify suitable alternative
coping mechanism
• Observe the patient continuously
• Suggestion therapy with IV pentothal, helpful in some cases.

24. 6. ALCOHOL INTOXICATION
• Also called as pathological intoxication
• Acute intoxication develops during or shortly after alcohol
ingestion.
Clinical manifestations of alcohol intoxication are:
- Maladaptive behavior
- Inappropriate sexual behavior
- Aggression
- Slurred speech
- In coordination
- Impaired memory
- Coma, stupor.

25. Management
• Take careful h/o patient & family
• Check the level of alcohol in blood regularly
• The signs are obvious at blood level of 150-200
mg% . Death can occur at level 400-8oo mg %
• Symptomatic management
• Start IV fluids

26. 7. LITHIUM TOXICITY
• The toxic effects of lithium can be seen at blood levels
above 2 mEq/l . It affects the CNS, thyroid, kidneys, GIT.
• The symptoms of toxicity are:
- Tremor
- Ataxia
- Nystagmus
- Confusion
- Diarrhea
- Vomiting , drowsiness, unsteadiness.

27. Management
• Immediately stop lithium therapy
• Replace fluid & electrolytes
• Dialysis may be needed in severe toxicity
• Enhance lithium excretion
• Management of symptoms are done accordingly
e.g. Dry mouth- give sips of water to patient
- Maintain oral hygiene of patient
- GI upset: make schedule for eating, start IV.
- Tremors: don’t leave the patient alone, advise the patient to take rest
- Polyuria, dehydration: maintain intake/ output chart of patient.

28. 8. Transient Situational Disturbances
• Characterized by disturbed feelings &
behavior occurring due to overwhelming
external stimuli
Management
• Reassure
• Mild sedation
• Allow the pt to ventilate
• Counseling by trained professionals

29. 9. Delirium tremens
• A condition resulting from withdrawal of alcohol:
• Clouding of consciousness with disorientation.
• Poor attention span and distractibility
• Hallucination, illusions(visual, auditory, tactile)
• Autonomic disturbance with tachycardia, fever., sweating, hypertension.
• Insomnia
• Dehydration with electrolyte imbalance
• Death, if occurs, is often due to: cardiovascular collapse, infection,
hyperthermia or self-inflicted injury.
Management
• Keep in safe quiet environment
• Symptomatic management
• Sedation with diazepam
• Maintain fluid & electrolyte balance
• Reassure the pt & family

30. 10. Epileptic Furor
• Strange – excited or violent behavior of the pt
following epileptic attack
Management
• Sedation
• Haloperidol to reduce psychotic behaviour

31. 11. Acute Drug-Induced EP Syndrome
• Acute symptoms resulting from side effects of
antipsychotic medications – EPS
• Neuroleptic malignant syndrome – rare but
serious
Management
• Stop the drug
• Symptomatic treatment
• Maintain nutrition & hydration
• Muscle relaxants
• Treat malignant hyperthermia

32. 12. Drug toxicity
• Drug overdose – accidental or suicidal
• Find out the drug
• Collect detailed history
• Symptomatic treatment promptly
• Look for symptoms
Management
• Administer O2, start IV
• Assess for cardiac arrhythmias
• Refer for haemodialysis
• Administer anticonvulsants

33. 13. Victims of disaster
• People survived a sudden, unexpected, overwhelming stress
• E.g. earthquake, floods, riots, terrorism
• Evidenced by – anger, frustration, guilt, numbness and
confusion
Management
• Treatment of life threatening physical problem
• Critical incident debriefing – to reduce discomfort
• Group therapy
• Sedation
• Referral to psychiatrist
• Teach coping strategies
• Educate about the available services

34. 14. Rape Victim
• Rape – an act of forceful sexual act with a female
against her will and consent
• Acute disorganization characterized by – self
blame, fear of being killed, feeling of degradation,
loss of esteem, depersonalization, de-realization,
recurrent intrusive thoughts, anxiety & depression
Management
• Be supportive, reassuring & non-judgmental
• Physical examination for injuries
• Morning after pill to prevent pregnancy
• Investigation for HIV & STD
• Complications of PTSD, Vaginismus.

35. Summary
• Definition & meaning of Psychiatric
emergencies
• Types of psychiatric emergencies
• Etiology of psychiatric emergencies
• Management of different types of psychiatric
emergencies

36. References
• Niraj Ahuja, A short textbook of Psychiaty, Jaypee
Brothers ,Sixth edition.
• Louise Rebraca Shives, Basic concept of psychiatric –
mental health nursing ,Lippincott Williams
&Wilkins,Seventh Edition.
• KP Neeraja, Essential of Mental Health &Psychiatric
Nursing, Jaypee Brothers Medical Publishers (p) LTD,
Volume 2.
• Katherine M. Fortinash, Psychiatric Nursing Care
Plans,Mosby, Fourth edition.