This document provides information on various psychiatric emergencies and their management. It defines psychiatric emergency and lists common emergencies such as suicidal threats, violence, panic attacks, and catatonic stupor. For each emergency, it discusses etiology, risk factors, symptoms and management strategies. It also covers topics such as stress, grief, crisis and crisis intervention techniques. The document serves as a reference for nurses on understanding and treating different psychiatric emergencies.

1. PSYCHIATRIC
EMERGENCY
Subraja.R
M.Sc (N) II year

2. Psychiatric Emergency
• Definition
Psychiatric emergency is a 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.

3. Initial approach during emergency

4. Initial approach during emergency
• The patient should be warm, directed and concerned.
• A quick evaluation to identify the nature of the condition
• Institute care on the basis of seriousness is essential.
• The emergency staff should have basic knowledge of handing
psychiatric emergency
• MC cases need to be registered separately and informed to the
concerned officer
• Hospital security must be adequate to control violent and dangerous
patient
• History and clinical findings should be recorded clearly in the
emergency file.
• Patient condition should be explained to the family members

5. COMMON PSYCHIATRIC
EMERGENCIES
• • Suicidal threat
• • Violent or aggressive behavior or excitement
• • Panic attacks
• • Catatonic stupor
• • Hysterical attacks
• • Transient situational disturbances

6. SUICIDALTHREAT
• In psychiatry a suicidal attempt is considered to be one of the
commonest emergencies.
• Suicide is a type of deliberate self-harm and is defined as an
intentional human act of killing oneself.

7. ETIOLOGY
•Psychiatric disorders
•Physical disorders
•Psychosocial disorders

8. RISK FACTORS
• Age
Males above 40years of age
Females above 55years of age
• • Sex
• Men have greater risk of completed suicide.
• suicide is 3 times more common in men than in women.
• women have higher rate of attempted suicide
• • Being unmarried, divorced, widowed or separated
• • Having a definite suicidal plan
• • History of previous suicidal attempts
• • Recent losses

9. SUICIDAL TENDENCY IN
PSYCHIATRIC WARD
• Major depression
• Schizophrenia
• Mania
• Drug or alcohol abuse
• Personality disorders
• Organic conditions

10. MANAGEMENT
• Be aware of certain signs which may indicate that the
individual may commit suicide.
• Monitoring the patient's safety needs
• Encourage verbal communication of suicidal ideas as well as
his/her fear and depressive thoughts. A 'no suicidal' pact may
be signed, which is a written agreement between the client
and the nurse, that client will not act on suicidal impulses,
but will approach the nurse to talk about them.
• Enhance self-esteem of the patient by focusing on his
strengths rather than weaknesses. His positive qualities
should be emphasized with realistic praise and appreciation.
This fosters a sense of self-worth and enables him to take
control of his life situation.

11. VIOLENT OR AGGRESSIVE
BEHAVIOR OR EXCITEMENT
• This is a severe form of aggressiveness. During this stage,
patient will be irrational, uncooperative, delusional and
assaultive.

12. ETIOLOGY
• Organic psychiatric disorders like, delirium, dementia,
Wernicke-Korsakoff’s psychosis.
• Other psychiatric disorders like, schizophrenia, mania, agitated
depression, withdrawal from alcohol and drugs, epilepsy, acute
stress reaction, panic disorder and personality disorders.

13. MANAGEMENT
• An excited patient is usually brought tied up with a rope or in chains. The first step
should be to remove the chains. A large proportion of aggression and violence is
due to the patient feeling humiliated at being tied up in this manner.
• Talk to the patient and see if he responds. Firm and kind approach by the nurse is
essential.
• Usually sedation is given. Common drugs used are: diazepam 10-20mg, IV;
haloperidol 10-20mg; chlorpromazine 50-100mg IM.
• Once the patient is sedated, take careful history from relatives; rule out the
possibility of organic pathology. In particular check for history of convulsions,
fever, recent intake of alcohol, fluctuations of consciousness.
• Carry out complete physical examination.
• Send blood specimens for hemoglobin, total cell count, etc.
• Look for evidence of dehydration and malnutrition.
• If there is severe dehydration, glucose saline drip may be started.

14. CON’T
• Have less furniture in the room and remove sharp instruments, ropes, glass
items, ties, strings, match boxes, etc. from patient's vicinity.
• Keep environmental stimuli, such as lighting and noise levels to a minimum;
assign a single room; limit interaction with others.
• Remove hazardous objects and substances; caution the patient when there is
possibility of an accident.
• Stay with the patient as hyperactivity increases to reduce anxiety level and
foster a feeling of security.
• Redirect violent behavior with physical outlets such as exercise, outdoor
activities.
• Encourage the patient to 'talk out' his aggressive feelings, rather than acting
them out.
• If the patient is not calmed by talking down and refuses medication,
restraints may become necessary.

15. CON’T
• Following application of restraints, observe patient every 15
minutes to ensure that nutritional and elimination needs are
met. Also observe for any numbness, tingling or cyanosis in the
extremities. It is important to choose the least restrictive
alternative as far as possible for these patients.
• Guidelines for self-protection when handling an aggressive
patient:
• never see a potentially violent person alone.
• keep a comfortable distance away from the patient (arm length).
• be prepared to move, a violent patient can strike out suddenly.
• maintain a clear exit route for both the staff and patient.

16. PANIC ATTACKS
• Episodes of acute anxiety and panic can occur as a part of
psychotic or neurotic illness.
• The patient will experience palpitations, sweating, tremors,
feelings of choking, chest pain, nausea, abdominal distress, fear
of dying, paresthesias, chills or hot flushes.
• Management
• • Give reassurance first
• • Search for causes
• • Diazepam 10mg or lorazepam
2 mg may be administered

17. CATATONIC STUPOR
• Stupor is a clinical syndrome of akinesis
and Mutism but with relative
preservation of conscious
awareness. Stupor is often
associated with catatonic signs
and symptoms (catatonic
withdrawal or catatonic stupor).
The various catatonic signs include
mutism, negativism, stupor,
ambitendency, echolalia,
echopraxia, automatic obedience,
posturing, mannerisms,
stereotypies, etc.

18. MANAGEMENT
• Ensure patent airway
• Administer IV fluids
• Collect history and perform physical examination
• Draw blood for investigations before starting any
treatment
• Other care is same as that for an unconscious patient

19. HYSTERICAL ATTACKS
• A hysteric may mimic abnormality of any function, which is
under voluntary control. The common modes of
presentation may be;
• • Hysterical fits
• • Hysterical ataxia
• • Hysterical paraplegia
• All presentations are marked
by a Dramatic quality and
sadness of mood.

20. MANAGEMENT
• Hysterical fit must be distinguished from genuine fits
(Seep. 122for differences between hysterical and epileptic
seizures).
• 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.

21. TRANSIENT SITUATIONAL
DISTURBANCES
• These are characterized by
disturbed feelings and behavior
occurring due to overwhelming
external stimuli.
• Management
• • Reassurance
• • Mild sedation if necessary
• • Allowing the patient to
ventilate his/her feelings
• • Counseling by an
understanding professional

22. DELIRIUM TREMENS
• Delirium tremens is an acute condition resulting from
withdrawal of alcohol.
• Management
• • Keep the patient in a quiet and
Safe environment.
• • Sedation is usually given with
Diazepam 10mg or lorazepam
4 mg IV, followed by oral
administration.
• • Maintain fluid and electrolyte
balance.
• • Reassure patient and family.

23. EPILEPTIC FUROR
• 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

24. ACUTE DRUG-INDUCED
EXTRAPYRAMIDALSYNDROME
• Antipsychotics can cause a 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.
• Management
• The drug should be stopped immediately.
• Treatment is symptomatic and includes cooling the patient,
maintaining fluid and electrolyte balance and treating inter-
current infections.
• Diazepam can be used for muscle stiffness. Dantrolene, a drug
used to treat malignant hyperthermia, bromocriptine,
amantadine and L- dopa have been used.

25. DRUG TOXICITY
• Drug over-dosage may be 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.

26. MANAGEMENT
• • Administer 02
• • Start IV line
• • Assess for cardiac arrhythmias
• • Refer for hemodialysis
• • Administer anticonvulsants

27. VICTIM DISASTER
• Victims of disaster are people, who have survived a sudden,
unexpected, overwhelming stress. This is beyond normally what
is expected in life, like in an earthquake, tsunami, flood, riots
and terrorism. Anger, frustration, guilt, numbness and confusion
are common features in these people.

28. MANAGEMENT
• Treatment for life threatening physical problems
• Critical incident debriefing (CID) is a special technique, which is
used to lessen the discomfort of the disaster victims.
• CID includes five phases: Fact, thought, reaction, reaching and re-
entry:
• Group therapy
• Benzodiazepines
• Mental health service
• Educate about available resources
• Teach about coping strategies.

29. STRESS

30. • STRESS
• Stress is the “non – specific response of the body to any kind
of demand made upon it.” (selye – 1956)
• Stress is the arousal of mind and body in responses to
demands made upon them (schafer - 2000)
STRESSORS
A stressor is any person or situation that produces anxiety
responses. Stress and stressors are different for each person;
therefore, it is important for the nurse to seek information
about stress producers for that patient. What is extremely
stressful for one person might be relaxing to someone else.

31. Types of stress

32. MODELS OF STRESS
•Stimulus - based model
•Response - based model
•Transaction - based model

33. STIMULUS - BASED MODEL

34. RESPONSE - BASED MODEL
STRESSOR
Stage I
ALARM
body prepares for
action, increased
arousal
Stage II
RESISTANCE
attempts are made
to cope with
specific stressor
Stage III
EXHAUSATION
body can no longer
resist stressor;
psychological
breakdown begins

35. ALARM REACTION
Stressor
Hypothalamous
Sympathetic nervous system
Adrenal medulla
Catecholamine
(epinephrine and norepinephrine produces)
Alarm reaction (fight or fight responses)
stimulates
stimulates
stimulates
Releases

36. RESISTANCE REACTION
STRESSOR
HYPOTHALAMOUS
CRH
GHRH
TRH
ANTERIOR PITUITARY
stimulates
Releases
stimulates
Releases

37. Con’t
ACTH HGH TSH
Adrenal cortex
Adrenal hormones
(Glucocorticiods
mineralocorticiods)
Liver
Supplies energy
through
glyconeogenesis
and increseased
breakdown of fats
Supplies energy through
increased breakdown of
carbohydrates
Thyroid gland

38. EXHAUSTION STAGE
• At this stage, the cells start to die, and the organs
weaken. A long-term resistance reaction puts heavy
demand on the body, particularly on the heart, blood
vessels and adrenal cortex, which may suddenly fail
under the strain. In this respect, ability to handle stressors
is to a large extent determined by the general health.

39. Stress Management Strategies
• 1. Take a Deep Breath
• 2. Practice Specific Relaxation Techniques
• 3. Manage Time
• 4. Connect with Others
• 5. Talk it Out
• 6. Take a "Minute" Vacation
• 7. Monitor Your Physical Comfort
• 8. Get Physical
• 9. Take Care of Your Body
• 10.Laugh
• 11.Know Your Limits
• 12.Think Positively

40. • 13.Clarify Your Values and Develop a Sense of Life Meaning
• 14.Compromise
• 15.Have a Good Cry
• 16.Avoid Self Medication
• 17.Look for the "Pieces of Gold" Around You

41. GRIEF
• Grief is a subjective state of emotional, physical and social
response to the loss of a valued entity.
• The loss may be real, in which case it can be substantiated by
others (e.g. death of a loved one),or perceived by the individual
alone, in which case it cannot be perceived or shared by others

42. STAGES OF GRIEF

43. RESOLUTION OF GRIEF
• Resolution of the process of mourning is thought to have
occurred when an individual can look back on the
relationship with the lost entity and accept both the
pleasure and the disappointments (both the positive and
negative aspects) of the association.

44. MALADAPTIVE GRIEF RESPONSES
• Prolonged Response
• Delayed or Inhibited Response
• Distorted Response

45. NURSING INTERVENTION
• • Provide an open accepting environment.
• • Encourage ventilation of feelings and listen actively.
• • Provide various diversional activities.
• • Provide teaching about common symptoms of grief.
• • Reinforce goal-directed activities.
• • Bring together similar aggrieved persons, to encourage
communication, share experiences of the loss and to offer
companionship, social and emotional support.

46. CRISIS
• Crisis is a state of disequilibrium resulting from the interaction
of an event with the individual's or family's coping mechanisms,
which are inadequate to meet the demands of the situation,
combined with the individual's or family's perception of the
meaning of the event (Taylor 1982).

47. TYPES OF CRISIS
• Maturational Crisis
• Situational Crisis
• Social Crisis

48. PHASES OF CRISIS
• Phases of Crisis
• Caplan (1964)has described four phases of crisis
• Phase I
• Phase II
• Phase III
• Phase IV

49. SIGNS AND SYMPTOMS OF CRISIS
• The major feeling in a crisis situation is anxiety. The
individual experiences a heavy burden of free-floating
anxiety.
• The anxiety may be manifested through depression, anger
and guilt. The victim will attempt to get rid of the anxiety
using various coping mechanisms, healthy or unhealthy.
• The individual may become incapable of even taking care
of his daily needs and may neglect his responsibilities.
• The individual may become irrational and blame others for
what has happened to him .

50. CRISIS INTERVENTION
• Aims of Crisis Intervention Technique
• To provide a correct cognitive perception of the situation.
• To assist the individual in managing the intense and
overwhelming feelings associated with the crisis
• A Steps to provide a correct cognitioe perception
• Assessment of the situation
• Defining the event
• Develop a plan of action
• B. Steps to assist the victim in managing the intense feelings
• Helping the individual to be aware of the feelings
• Help the individual to attain mastery over the feelings