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![Following epileptic attack patient may
behave in a strange manner and become
excited and violent
MANAGEMENT:
※Sedation: Inj. Diazepam 10 mg IV [or]
Inj. Luminal 10 mg IV followed by oral
anticonvulsants
※Haloperidol 10 mg IV helps to reduce
psychotic behaviour.](https://image.slidesharecdn.com/psychiatricemergencies-200409065803/85/Psychiatric-emergencies-63-320.jpg)
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Psychiatric emergencies
A psychiatric emergency is a disturbance in thoughts, feelings, or actions that requires immediate treatment to protect the patient's life and safety as well as others. Common types of psychiatric emergencies include suicide attempts, violence, panic attacks, psychosis from drug or alcohol withdrawal, and extreme mental states like catatonia. Immediate interventions may involve de-escalation, sedation, and treating any life-threatening conditions present while evaluating the underlying cause of the emergency.
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Psychiatric emergencies
- 3. ☻Psychiatric emergency isa condition wherein the patient has disturbances of thought, affect and psychomotor activity leading to a threat to his existence (suicide), or threat to the people in the environment (homicide). ☻This condition needs immediate intervention to safeguard the life of the patient, bring down the anxiety of the family members and enhance emotional security to others in the environment.
- 5. A psychiatric emergencyis a disturbance in thoughts, feeling or actions that requires immediate treatment. (Kaplan and Sadock)
- 7. ¶Any condition/ situationmaking the patient & relatives to seek immediate treatment. ¶Disharmony between subject and environment ¶Sudden disorganization in personality which affects the socio-occupational functioning.
- 9. ⁂To enhance emotionalsecurity of others in the environment. ⁂To bring down the anxiety of family members. ⁂To safeguard the life of patient.
- 10.
- 11. ⁕Suicide or deliberateself harm ⁕Violence or excitement ⁕Stupor. ⁕Panic ⁕Withdrawal symptoms of drug dependence. ⁕Alcohol or drug over dose. ⁕Delirium ⁕Epilepsy or status epileptics ⁕Severe depression (suicidal or homicidal tendencies, agitation or stupor) ⁕Iatrogenic emergencies
- 12. Side effects ofpsychotropic drugs Extra pyramidal syndrome Dystonia Akathisia Mania due to antidepressants Lithium toxicity Psychiatric complications of drugs used in medicine ( eg: INH, steroids, etc.) ⁕Abnormal responses to stressful situations.(dangerousness of the patient’s behavior) ⁕Others(acute psychiatric condition, battered baby syndrome, ICU syndrome)
- 13.
- 14. One of thecommonest psychiatric emergency. Commonest cause of death among psychiatric patients. Attempted suicide is an unsuccessful suicidal act with a nonfatal outcome.
- 15.
- 16. One among thetop 10 causes of death Suicide rate in India – 10.8 per 1 lakh population Male to female ratio – 64 : 36 Highest in the age group 15-29 yrs Methods used jumping in front of train or vehicle (3%) Drowning (6.7%) Burning (8.8%) Hanging (32.2%) Ingestion of poison (34.8%)
- 17. DEFINITION Suicide is definedas the intentional taking of one’s life in a culturally non-endorsed manner.
- 18. ETIOLOGY Psychiatric disorders ‽Major depression ‽Schizophrenia ‽Drugor alcohol abuse ‽Dementia ‽Delirium ‽Personality disorder
- 19. Physical disorders •Chronicor incurable physical disorders like cancer, AIDS Psychosocial factors •Failure in examination •Dowry harassment •Marital problems •Loss of loved object •Isolation and alienation from social groups •Financial and occupational difficulties
- 20. RISK FACTORS Male gender Stayingsingle Previous suicidal attempts Depression ⁕Presence of guilt, nihilistic ideation, worthlessness ⁕Higher risk after response to treatment ⁕Higher risk in the week after discharge
- 21. Suicidal preoccupation Alcohol ordrug dependence Chronic illness Recent serious loss or major stressful life event Social isolation Higher degree of impulsivity
- 22. WARNING SIGNS FORSUICIDE
- 23. Appearing depressed orsad most of the time Feeling hopeless, expressinghopelessness Withdrawing fromfamilyand friends Sleeping toomuch or too little Making overt statements like“I can’t take it anymore”;“I wish I were dead” Loosing interest in most activities Giving away prizedpossessions Making out a will Being preoccupiedwith deathor dying Neglecting personal hygiene Making covert statements like “it’s okay now, everything will be fine”; “I wont be a problemfor much longer”
- 24. COMMON MISCONCEPTION ABOUTSUICIDE ⱺPeople who talk about suicide do not complete suicide ⱺPeople who attempt suicide really want to die ⱺSuicide happens without any warning ⱺOnce people decide to die by suicide, there is nothing you can do to stop them ⱺAll suicidal individuals are mentally ill. ⱺOnce a person is suicidal, he is suicidal forever
- 25.
- 26. Be aware ofthe warning signs Monitor the patient’s safety needs Take all suicidal threats or attempts seriously Search for toxic agents such as drugs/ alcohol. Do not leave the drug tray within reach of the patient Make sure that daily medication is swallowed Remove sharp instruments from the environment Do not allow the patient to bolt the door from inside. Somebody should accompany to the bathroom. Patient should never be left alone
- 27. Remove straps andclothing such as belts Spent time with patient; allow ventilation of emotions Encourage to talk about his suicidal plans/ methods In case of severe suicidal tendency – sedation A ‘ no suicide’ agreement may be signed Enhance self esteem by focusing on his strengths. Acute psychiatric emergency interview Counseling and guidance
- 28. To deal withongoing life stressors and teaching new coping skills Treatment of psychiatric disorders
- 29.
- 30. Violence is byone person on another. It is important to note that most violent individuals are not psychiatrically ill. Violence is most commonly associated with psychiatric disorder, personality disorder, drug intoxication or withdrawal, mental retardation.
- 31. Do’s ֎Do protect yourself ֎Unarmthe patient ֎Keep the doors open ֎Do restraint if necessary ֎Assert authority ֎Show concern, establish rapport and assure the patient
- 32. Don’ts Do note keeppotential weapon near the patient Do not sit with back to the patient Do not wear neck tie or jewellery Do not keep any provocative family member or friend in the room Do not confront Do not sit close to the patient
- 33. GUIDELINES FOR SELF PROTECTIONWHILE HANDLING AN AGGRESSIVE PATIENT
- 34. Never see thepatient alone Keep a comfortable distance away from patient Be prepared to move Maintain a clear exit route Be sure that the patient has no weapons with him If patient is having a weapon, ask him to keep it down rather than fighting with him Keep something (pillow, mattress, blanket)between you and weapon. Distract the patient to remove the weapon (eg; throwing water on the face) Give prescribed antipsychotics
- 35. MANAGEMENT Untie the patient,if tied up Reassurance oTalk to the patient softly oFirm and kind approach is essential oAsk direct and concise questions oAvoid yes or no questions oAssist the patient in defining the problem Sedation oChlorpromazine 50-100 mg IM oHaloperidol 2-10 mg IM/IV oDiazepam 5-10 mg slow IV
- 36. Collect detailed historyand explore the cause Carry out complete physical examination Check hydration status; if severe dehydration– IV fluids Have less furniture in the room, remove all sharp instruments Keep environmental stimuli to the minimum Stay with the patient to reduce anxiety Redirect violent behavior with physical outlets such as exercise, outdoor activities Encourage the patient to ‘talk out’ the aggressive feelings rather than acting them out.
- 37. GUIDELINES oApproach patient fromfront oNever see a potentially violent patient alone oHave a 4 member team to hold each extremity oKeep talking while restraining oDo not leave the unattended after restraining oObserve every 15 minutes for any numbness, tingling or cyanosis in the extremities. oEnsure that nutritional and elimination needs are met.
- 38.
- 39. DEFINITION Stupor is definedas a state of diminished consciousness in which the patient remains mute and still although the eyes remain open and many follow external objects. Catatonic states may manifest through negativism, catalepsy, mutism , stereotypes, verbigeration, echolalia and echopraxia, and impulsiveness.
- 40. MANAGEMENT •Ensure patent airway •Maintainhydration (Ryle’s tube feeding or IV fluids) •Check vital signs •History and physical examination •Draw blood for investigation before starting any treatment •Identify the specific cause and treat •Provide care for an unconscious patient •Care of skin, nutrition, elimination and personal hygiene is required •Give ventillatory support if needed.
- 41.
- 42. Episodes of acuteanxiety and panic – occur as a part of psychotic or neurotic illness
- 43. MANIFESTATIONS Palpitations Sweating Tremors Feelings of choking Chestpain Nausea Abdominal distress Fear of dying Paresthesia Hot flushes
- 44. MANAGEMENT Give reassurance Search forcauses Inj. Diazepam 10 mg or Lorazepam 2 mg Counsel the patient and relatives Use behavior modification techniques
- 45.
- 46. People who havesurvived a sudden, unexpected, overwhelming stress
- 47.
- 48.
- 49. Treatment of thelife threatening physical problem Intervention Listen attentively Do not interrupt Acknowledge understanding of the pain& distress Look into their eyes Console them – patting on the shoulders / touching /holding their hands Use silence Do not ask them to stop crying Provide accurate and responsible information Group therapy Benzodiazepines to reduce anxiety
- 50. Referral to mentalhealth service, if required. Educate about the available resources Teach them that these reactions are normal to these type of situations. Teach coping strategies to avoid the development of crisis.
- 52. A hysteric maymimic abnormality of any function, which is under voluntary control. The common modes of presentation may be: Hysterical fits Hysterical ataxia Hysterical paraplegia
- 54.
- 55. All presentations aremarked by a dramatic quality and sadness of mood. Hysterical fit must be distinguished from genuine fits. As hysterical symptoms can cause panic among relatives, explain to the relatives the psychological nature of symptoms. Reassure that no harm would come to the patient Help the patient realize the meaning of symptoms, and help him find alternative ways of coping with stress. Suggestion therapy with IV pentothal may be helpful in some cases.
- 56.
- 57. These are characterizedby disturbed feelings and behaviour occurring due to overwhelming external stimuli.
- 58. MANAGEMENT: Reassurance Mild sedation ifnecessary Allowing the patient to ventilate his/her feelings Counseling by an understanding professional
- 59.
- 60. Delirium tremens isan acute condition resulting from withdrawal of alcohol.
- 61. MANAGEMENT: ⁂Keep the patientin a quiet and safe environment. ⁂Sedation is usually given with diazepam 10mg or lorazepam 4mg IV, followed by oral administration. ⁂Maintain fluid and electrolyte balance. ⁂Reassure patient and family
- 63. Following epileptic attackpatient may behave in a strange manner and become excited and violent MANAGEMENT: ※Sedation: Inj. Diazepam 10 mg IV [or] Inj. Luminal 10 mg IV followed by oral anticonvulsants ※Haloperidol 10 mg IV helps to reduce psychotic behaviour.
- 64.
- 65. Antipsychotics can causea variety of movement- related side-effects, collectively known as Extra Pyramidal Syndrome (EPS). Neuroleptic malignant syndrome is rare but most serious of these symptoms and occurs in a small minority of patients taking neuroleptics, especially high- potency compounds.
- 66. •The drug shouldbe stopped immediately. Treatment is symptomatic and includes cooling the patient, maintaining fluid and electrolyte balance and treating intercurrent infections. •Diazepam can be used for muscle stiffness. Dantrolene, a drug used to treat malignant hyperthermia, bromocriptine, amantadine and L- dopa have been used. MANAGEMENT
- 67.
- 68. Drug over-dosage maybe accidental or suicidal. In either case all attempts must be made to find out the drug consumed. A detailed history should be collected and symptomatic treatment instituted. A common case of drug poisoning is lithium toxicity. The symptoms include drowsiness, vomiting, abdominal pain, confusion, blurred vision, acute circulatory failure, stupor and coma, generalized convulsions, oliguria and death.
- 69. MANAGEMENT •Administer Oxygen •Start IVline •Assess for cardiac arrhythmias •Administer anticonvulsants •Refer for haemodialysis
- 70.
- 71. Psychiatric emergencies areoften, but not always, caused by mental illness. They require action without delay to save the patient and other persons from mortal danger or other serious consequences . Immediate treatment directed against the acute manifestations is needed, both to improve the patient’s subjective symptoms and to prevent behavior that could harm the patient or others.