Psychiatric Emergencies

2014/2015
Suicide
Suicide is derived from Latin, self-murder.
It is a fatal act that fulfills the persons wish to die.
Defination
Suicide
-self-inflicted death with evidence either explicit or implicit that the
person intended to die.
Suicide attempt
- self-injurious behavior with a nonfatal outcome accompanied by
evidence that the person intended to die.
Parasuicidal
- patients who injure themselves by self-mutilation but usually do
not wish to die.
Suicidal ideation
- thoughts of wanting to die; may vary in seriousness depending in
the specificity of suicide plans and degree if suicide attempt.
Epidemiology
Incidence
- About 35000 persons commit suicide per year in
US.
- Rate 12.5 persons per 10000.
- About 250000 persons attempt suicide per year.
Risk Factors
Gender- men commit suicide three times more often
than women. Women attempt suicide four times more
than men.
Methods- men has higher rate of successful suicide is
related to the methods they use eg: firearms, hanging,
while women more commonly take overdose
psychoactive substances or a poison.
Age- Rates increase with age
Marital status- rate is twice as high in single persons
than in married persons.
Physical health- medical or surgical illness is a high-
risk factor, especially if associated with pain or chronic
or terminal illness.

Risk Factors
Mental illness- depressive disorder, schizophrenia,
alcohol and other substance dependence, personality
disorder and anxiety disorder.
Unambigious wish to die
Sense of hopelessness
Unemployment
Hoarding pills
Access to lethal agents or to firearms
Family history of suicide or depression
Fantacies of reunion with the deceased loved ones
Occupation- dentist, physician, scientist, police officer
Previous suicide attempt
History of childhood abuse
History of impulsive or aggressive behaviour

Management
General strategy in evaluating patients
l. Protect yourself
- Know as much as possible about the patients before
meeting them
- Leave physical restraint procedures to those who are
trained to handle them
- Be alert to risks of impending violence
- Attend to the safety of physical surroundings.
- Have other present during assessment, if needed.
- Have others in vicinity
- Attend to developing alliance with patient
Management
II. Prevent harm
-Prevent self-injury and suicide.
-Prevent violence toward others. During the evaluation, briefly assess the
patient for the risk of violence. If the risk is significant, consider the
following option:
~Inform patient violence is not acceptable
~Approach the patient in nonthreatening manner
~Reassure and calm the patient or assist in reality testing
~Offer medication
~Inform the patient that restrain or seclusion will be use if necessary
~have team ready to restrain the patient
~when the patient is restrained, always closely monitor them and their
vital sign. Isolate restrained patients from agitating stimuli. Immediatelya
further approach- medication, reassurance, medical evaluation.
III. Rule out cognitive disroders
IV. Rule out impending psychosis
VIOLENCE
Definition
Intentional act of doing bodily harm to another
person
Includes assault, rape, robbery, homicide
Physical and sexual abuse violent acts
Disorders a/w violence
Schizophrenia
Acute mania
Alcohol/drugs intoxication, withdrawal
Catatonic excitement
Agitated depression
Personality disorders
Cognitive disorders
Approach to a Violent Patient
1. Protect yourself
Be on guard for a sudden violent act
Never interview an armed patient
Never interview a potentially violent patient
alone/ in a closed office
Have a route of rapid escape in case the patient
attacks
Do not sit close to a paranoid patient
Do not challenge or confront a psychotic patient
2. Risk Assessment
Signs of Impending Violence
- Recent acts of violence
- Verbal/physical threats
- carrying weapons
- progressive psychomotor agitation
- Alcohol/ subtance intoxication
- paranoid features
- command hallucination
- catatonic excitement
- Certain manic episodes
- Certain agitated depressive episodes
- Personality disorders

Assess the risk for violence
Violent ideation, intention, wish, plan,
implementation of plan, wish for help
Demoraphics male, age 15-24, low SES, few
social supports
Consider patients history
Overt stressors

Strategies to Gain Control
1. Restraints and seclusion
2. Pharmacologic interventions (Chemical
restraints)
Restraints and seclusion
Seclusion
Useful for agitated patients by decreasing the
external stimuli
Permitting the patient time-out to regain
behavioral control
A seclusion room must be safe, above all, and
free of objects that could be used to injure self
or others
Restraints and seclusion
Restraints
used when patients are so dangerous to
themselves or others that they pose a severe
threat that cannot be controlled in any other
Done swiftly and humanely
Explanation of the reason for restraints given
Restraint application
Sufficient manpower (A minimum of 4-5 staff
members)
Provide the patient or family with an ongoing
explanation of the reasons for the procedure, and
what to expect.
Secure all four limbs firmly to the bedframe, snug
without impairing circulation.
Elevate the patients head slightly to minimize the
risk of aspiration
Monitor the patient


Pharmacologic Intervention
Depends on specific diagnosis
Benzodiazepine or antipsychotics used as
tranquilizers
Haloperidol 5mg oral/IM
Risperidone 2mg oral
Lorazepam 2mg oral/IM
If patient is already on antipsychotics, give more
of the same drug
If agitation not decreased in 20 to 30 minutes,
repeat the dose

Other psychiatric emergencies
Disturbance in thoughts, feelings or actions that
require immediate treatment
Can be caused or accompanied by medical or
surgical condition requires timely evaluation
and treatment
Address problem is medical, psychiatric, or both
Medical conditions (Thyroid disease, Acute
intoxication, Withdrawal states, head traumas)
can present with mental status changes that can
mimic psychiatric illness

EXTRAPYRAMIDAL
SYMPTOMS
Akathisia, dustonia, parkinsonism, dyskinesia
Antipsychotic-induced side effects
Symptoms can develop acutely, delayed or
overlap
Most EPS will subside with discontinuation/
lowering the dosage
Replace with atypical antipsychotic to reduce the
risk of EPS


Neuroleptic Malignant Syndrome
Rare, Idiosyncratic reaction dt acute dopamine
blockade
Risk factors- high ambient temperature, dehydration,
rapid antipsychotic initiation/ dose escalation,
withdrawal of antiparkinsonian drugs, history of
organic brain disease, previous NMS.
Signs and Symptoms Fever, muscular rigidity,
diaphoresis, labile BP, delirium, autonomic
dysfunction.
Mortality: 5-20%-- death usually dt respiratory failure,
cardiovascular collapse, arrhythmia, DIC.

Delirium tremens
Most severe form of alcohol withdrawal
Manifested by altered mental status autonomic
hyperactivity can progress to cardiovascular
collapse
Occur 3-10 days following the alst drink
Requires immediate hospitalization for
stabilization
IV fluid
Anticonvulsants
Benzodiazepines
antipsychotics
-
Common psychiatric
emergencies
Abuse of children/adult
Adjustment disorder
Agoraphobia
Akathisia
Alcohol related emergencies intoxication,
withdrawal
Subtance abuse amphetamine,cocaine
Acute anxiety
Delirium, dementia
Delusions
Depression
Hallucinations
Lithium Toxicity
Mania
Opiod intoxication or withdrawal
Panic reactions
Paranoia
Psychosis
Schizophrenia