Almost all people affected by emergencies will experience psychological distress which for most people will improve over time.People with severe mental disorder are especially vulnerable during emergencies and need access to mental health care and other basic needs.

1. BHARATI VIDYAPEETH (DEEMED TO BE UNIVERSITY) COLLEGE OF NURSING, PUNE
PRACTICE TEACHING
ON
PSYCHIATRIC EMERGENCIES
BY,
MS SHWETA GODSE

2. OBJECTIVES
•Define psychiatric emergencies.
•Discuss history of psychiatric emergencies.
•Enlist the common psychiatric emergencies.
•Explain the objectives of psychiatric emergencies
•Discuss the characteristics of psychiatric emergencies
•Explain the management of psychiatric emergencies.

3. INTRODUCTION
 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.

4. DEFINITION
Psychiatric emergencies are acute changes in behavior
that negatively impact a patient's ability to function in
his or her environment. Often such patients are in a
state of crisis in which their baseline coping
mechanisms have been overwhelmed by real or
perceived circumstances.

5. OBJECTIVES OF PSYCHITRIC EMERGENCY
INTERVENTION
•To safeguard the life of patient
•To reduce the anxiety
•To provide the emotional security
•To educate the client and family members

6. CHARACTERISTICS OF PSYCHITRIC
EMERGENCIES
•Unable to cope with the stressful situation or family
in handling the stressors.
•Sudden unexpected disorganization in person.

7. •Disharmony between client and his environment.
•Certain condition or stressor predisposes the client
family members to seek immediate intervention as
they feel more discomfort.

9. SUICIDAL
THREAT

10. DEFINITION
Suicide is defined as the intentional taking of one's
own life.
OR
Suicide is a type of deliberate self-harm and is defined
as an intentional human act of killing oneself.

11. ETIOLOGY
1) Psychiatric Disorders
•Major depression
•Schizophrenia
•Drug or alcohol abuse
•Dementia
•Delirium
•Personality disorder
2) Physical Disorders
•Patients with incurable or painful physical disorders
like, cancer and AIDS.

12. •Psychosocial Factors
•Failure in examination Dowry difficulties Loss of loved object
Marital difficulties
•Isolation and alienation Financial and
from social groups occupational difficulties

13. RISK FACTORS FOR SUICIDE
• Age
Males above 40years of age
Females above 55years of age
• Gender
•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

14. SUICIDAL TENDENCY IN PSYCHIATRIC
WARDS
Major depression
Schizophrenia
Mania
Drug or alcohol abuse
Personality disorder
Organic conditions

15. MANAGEMENT
1. Be aware of certain signs which may indicate that
the individual may commit suicide, such as:
• Suicidal threat
• Writing farewell letters
• Giving away treasured articles making a will
• Closing bank accounts
• Appearing peaceful and happy after a period of depression
• Refusing to eat or drink, maintain personal hygiene.

16. 2. Monitoring the patient's safety needs:
• Take all suicidal threats or attempts seriously and
notify psychiatrist
• Search for toxic agents such as drugs/ alcohol
• Do not leave the drug tray within reach of the
patient, make sure that the daily medication is
swallowed
• Remove sharp instruments such as razor blades,
knives, glass bottles from his
environment.
.

17. • Remove straps and clothing such as belts, neckties.
• Do not allow the patient to lock his door on the
inside, make sure that somebody accompanies him to
the bathroom.
• Patient should be kept in constant observation and
should never be left alone
• Have good vigilance especially during morning
hours.

18. • Spend time with him, talk to him, and allow him to
ventilate his feelings.
• Encourage him to talk about his suicidal plans
Imethods
• If suicidal tendencies are very severe, sedation
should be given as prescribed

19. 3. Encourage verbal communication of suicidal
ideas as well as his/her fear and depressive thoughts.
4. Enhance self-esteem of the patient by focusing on
his strengths rather than weaknesses.

20. VIOLENT OR
AGGRESSIVE BEHAVIOR
OR EXCITEMENT

21. This is a severe form of aggressiveness. During this
stage, patient will be irrational, uncooperative,
delusional and assaultive.

22. ETIOLOGY
• Organic psychiatric disorders like, delirium,
dementia
•Other psychiatric disorders like, schizophrenia,
mania, agitated depression, withdrawal from alcohol
and drugs, epilepsy, acute stress reaction, panic
disorder and personality disorders.
.

23. MANAGEMENT
• Restrain the patient.
Physical – Chemical
• Talk to the patient and see if he responds.
• 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.
• In particular check for history of convulsions, fever,
recent intake of alcohol, fluctuations of consciousness.

24. • Carry out complete physical examination.
• Have less furniture in the room and remove sharp
instruments, ropes, glass items, ties, strings, match
boxes, etc. from patient's vicinity.
• 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.

25. 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.
be sure that the patient has no weapons in his possession
before approaching him.
• If patient is having a weapon ask him to keep it on a table or
floor rather than fighting with him to take it away.
• Give prescribed antipsychotic medications.

26. PANIC
ATTACKS

27. 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

28. CATATONIC STUPOR

29.  Stupor is a clinical syndrome
of akinesis and mutism but with
relative preservation of
conscious awareness.
 The various catatonic signs
include mutism, negativism,
stupor, ambitendency,
echolalia,echopraxia, automatic
obedience, posturing,
mannerisms, stereotypies, etc.

30. MANAGEMENT
• Ensure patent airway
• Administer IV fluids
• Collect history and perform physical examination
• Draw blood for investigations before starting any
treatment

31. HYSTERICAL
ATTACKS

32. Hysterical means "marked by uncontrollable, extreme
emotion."
A hysteric may mimic abnormality of any function,
which is under voluntary control. The common modes
of presentation may be .
• Hysterical fits
• Hysterical ataxia (inability to coordinate limb
movements
• Hysterical paraplegia
All presentations are marked by a dramatic quality and
sadness of mood.

33. MANAGEMENT
• 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 IVpentothal may be helpful
in some cases.

34. 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

35. •ORGANIC PSYCHIATRIC EMERGENCIES
1. Delirium tremens
2. Epileptic furor
3. Acute drug-induced syndrome
4. Drug toxicity Extra pyramidal

36. 1) 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.

37. 2) EPILEPTIC FUROR
Following epileptic attack patient may behave in a
strange manner and become excited and violent.
MANAGEMENT
• Sedation – Inj. Diazepam 10 mg
IV – Inj. Haloperidol 10 mg IV
•IV followed by oral anticonvulsants.
• Haloperidol 10 mg IV helps to reduce psychotic
behaviour.

38. 3) ACUTE DRUG-INDUCED
EXTRAPYRAMIDAL SYNDROME
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 potencycompounds.

39. MANAGEMENT
The drug should be stopped immediately.
Cool the patients body temperature
 Maintain Fluid and electrolyte balance
Diazepam for muscle relaxation
Dantrolene to treat malignant hyperthermia

40. 4) 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.

41.  A common case of drug poisoning is lithium
toxicity.
The symptoms include drowsiness,vomiting,
abdominal pain, confusion, blurredvision, acute
circulatory failure, stupor and coma,generalized
convulsions, oliguria and death.

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

43. RAPE / SEXUALASSULT
DEFINITION
Unlawful sexual activity and usually sexual
intercourse carried out forcibly or under threat of
injury against a person's will or with a person who is
beneath a certain age or incapable of valid consent
because of mental illness, mental deficiency,
intoxication, unconsciousness, or deception.

44. SIGNS & SYMPTOMS:
 Acute disorganization characterized by self blame,
fear of being killed, feeling of degradation and loss of
self esteem, feelings of depersonalization and
derealisation, recurrent intrusive thoughts, anxiety and
depression are commonly seen.
 Long term psychological effects like post traumatic
stress disorders (PTSD) can occur in some cases.

45. MANAGEMENT
•Be Supportive, reassuring and non – judgmental.
•Give morning after pill to prevent possible pregnancy.
•Physical examination for any injuries.
•Send samples for STD & HIV infection.
•Explain to the patient the possibility of PTSD, sexual
problems like vaginismus and anorgasmia which may
appear later.

46. VICTIMS OF DISASTER
Victims of disaster are people, who have survived a
sudden, unexpected, overwhelming stress.
EXAMPLE:- Earthquake, flood, riots and terrorism
S/S :-Anger, frustration, guilt, numbness and
confusion are common features in these people.

47. MANAGEMENT
•Treatment for life threatening physical problems
•Group therapy
•In selected cases benzodiazepines are prescribed to reduce
anxiety and induce sleep.
•Educate the victims that these emotional reactions are normal
reactions to an extraordinary and abnormal situation, and are
to be expected under the circumstances.
•Educate about the available services.
•Referral to mental health service, if required
•Teach coping strategies to avoid the development of the
crises.
For example, strategies to be taught can include how to
request information, access resources and obtain support.

48. SUMMARY
Today we have seen definition, history, objectives,
characteristics of psychiatric emergencies and
common psychiatric emergencies and their
management.

49. CONCUSION
The increasing incidence of alcohol and substance
abuse in our country as well as the rise in levels of
unipolar depression, have led to an increased number
of patients reporting to the emergency care unit. It is
necessary for all clinicians to be familiar with
common psychiatric emergencies especially suicide
attempts and violent behaviour and other psychiatric
emergencies so as to improve the level of care offered
to the patients.

50. BIBLIOGRAPHY
•R Sreevani, A guide to Mental Health and
Psychiatrics Nursing, Jaypee Brothers 4th edition,
page no 305
•KP Neeraja, Essentials of Mental Health and
Psychiatric Nursing, Volume two, Jaypee, Page No
304 - 335
•Niraj Ahuja, A short textbook of psychiatry, 6th
edition, Jaypee, page No. 235
•http://emed.ie/Psychiatry/Emergencies.php
•https://www.slideshare.net/
•https://medical-
dictionary.thefreedictionary.com/suicide