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PRESENTER-
DR ANGSHUMANKALITA
DISCUSSANT-
DR NABANITA SENGUPTA
CHAIRPERSON-
ASSO PROF DR DEEPANJALI MEDHI
PSYCHIATRIC EMEG...
INTRODUCTION
Definition:
A psychiatric emergency is any disturbance in thoughts,
feelings or actions for which immediate t...
Definition:
Psychiatric emergencies in children are those clinical
situations where there is direct & immediate threat to ...
HISTORY
 Originated in Russo-Japanese War (1904-1905)
 Psychiatrist in the Imperial Russian Army treated psychiatric
eme...
In a study titled ‘Psychiatric emergencies in children’ done
by Christodulu et al it was found that during a 13 month
per...
In another study titled ‘Disproportionately Increasing
Psychiatric Visits to the Pediatric Emergency
Department Among the...
WHO NEEDS EMERGENCY CARE?
Healthy children- faced with adverse & sudden significant
life events, e.g. crisis, disaster, b...
SPECIAL ISSUES
Since most children & adolescents are basically
dependant on their parents, it is they & not the children
...
Apart from parents, it may sometimes be teachers,
pediatricians & rarely police or other social agencies may
refer the ch...
Most emergencies occur within the family or the school
setting
Often give warning signals before becoming emergent
Many...
APPROACH TO EMERGENCY PSYCHIATRIC
DIAGNOSIS
 Psychiatrist must perform rapid assessment with the goal of developing an
im...
DISORDERS THAT ARE LIKEKY TO PRESENT
AS EMERGENCIES
1. Severe depression & suicide
2. Dissociative disorders
3. Anxiety & ...
CLINICAL MANIFESTATIONS
Irrespective of the diagnosis, these disorders may present as any
of the following emergent clinic...
These presenting symptoms do not necessarily
corresponds to a specific psychiatric diagnosis. These are
symptoms of child...
FITS OR IMPAIRED CONSCIOUSNESS
One of the common & most dramatic presentations
in ER
C/c- “Fits”
Ch by-symptoms of impa...
Often interspersed with periods of recovery
Consciousness-impaired, not totally lost; may show
response to deep painful ...
Dissociative disorder:
Present as trance like states
Do not remember chunk of their behavior
May even exhibit psychotic...
Management:
Since dissociative disorder occurs in the setting of hostile,
threatening & abusive environment; the clinicia...
Immediate relief from symptoms can be obtained by
providing a reassuring nonthreatening & protective
environment, isolati...
Apart from environmental intervention, such a child is
treated with a variety of psychotherapeutic methods
including play...
SUICIDAL BEHAVIOUR
One of the common reasons
Most children under 12 years of age who threaten or
attempt suicide may not...
A sad generation?
 Suicide is the third leading cause of death in the 15-24
age group (follows unintentional injuries & h...
Risk factors
Loss of parent before the age of 12
History of parental abuse
Early onset of suicidal behavior (prepuberta...
Acute psychosocial stress
One in four adolescents that completed suicides show evidence
of planning
The most common dia...
NON SUICIDAL SELF INJURY NSSI
Non-suicidal self-injury is the direct, deliberate
destruction of one’s own body tissue in the absence of
intent to die.
...
Preceding the act of self-injury is a psychological
experience of increasing anger, tension, anxiety, dysphoria
and gener...
Prevalence
Most studies found prevalence ranging from 15 to 25% in
young adults and adolescents.
Along with BPD, seen in...
NSSI and Suicidality
NSSI is the strongest predictor of future suicide attempts
in adolescents
High levels of depression...
 Assessment must refer to the totality of the event &
circumstances surrounding the act-severity & persistence
of suicida...
Management
 Hospitalization- initially in medical/surgical unit.
 Psychiatric hospitalization-high risk for suicide, evi...
Characteristics of psychiatric units
 Ground floor
 Easily observable rooms.
 Weapons, toxic substances, electrical dev...
AGGRESSIVE & VIOLENT BEHAVIOUR
 May be a manifestation of underlying psychotic disorder like
schizophrenia or BPAD, ADHD,...
 The first task in such an emergency is to assess the risk & safety of
the child & of those around him
 Do’s
1. Protect ...
Don’ts
1. Do not keep any potential weapon near the patient
2. Do not sit with back to patient
3. Do not wear neck tie or ...
 During this process, a quick MSE should be done
specially looking for signs of major psychiatric illness.
 Presence of ...
Management:
1. Physical restraint, if necessary
2. Oral or may be parenteral ( if uncooperative) medication
in form of IM ...
 Methods of physical restraint
1. Use judiciously for the minimum period of time
2. Explain to the patient the reason for...
8. Patient should be restrained with legs spread eagled & one
arm restrained to one side & other arm restrained over
patie...
SECLUSION
 INDICATION
Therapeutic isolation for limiting provocative
environmental stimulation (Agitated patient) e.g.
p...
Seclusion cell in LGBRIMH,Tezpur
(NOT practised now a days)
 In certain situations where aggression & violence has
occurred d/t conflict between child & parent, a gentle &
calm appr...
 They can be handled psychologically where a
communication is established with a therapist & an
understanding is reached ...
ABNORMAL BEHAVIOUR
Sudden appearance of abnormal behavior
psychomotor excitement
Stupor
irrelevant speech
abnormal mot...
Management:
 Level of consciousness must be ascertained
 Neurological assessment must be done- to r/o neurological
cause...
 Often schizophrenia & affective disorders takes days or
weeks to develop. In some cases the onset of psychosis
may be ab...
 Sometimes abnormal behavior is not of psychotic
proportions or there are no psychotic symptoms. It can
occur following a...
 Medication may be given as necessary to counteract
manifest anxiety or depression or psychotic behavior
 Patient who sh...
REFUSAL TO EAT & SEVERE WEIGHT
LOSS
 Rare, but life threatening emergencies
 Usually encountered in adolescent females.
...
 Patients go into a medical emergency due to
complications of starvation:
1. Dehydration
2. Dyselectrolytemia
3. Hypoglyc...
 Bulimia nervosa- Sometimes patients goes into bouts of
overeating followed by extreme steps to control body
weight like ...
Management:
Hospitalization
Immediate assessment of the functioning of vital organs like-
ECG, CBC, S. electrolytes, RFT...
 Psychological assessment& psychiatric evaluation
 Family members are explained the seriousness of the
disease
 Further...
PARALYSIS, PARESIS, LOSS of BODILY
SENSATIONS
Sometimes patients are brought to emergency with sudden
development of weak...
Points against a diagnosis of neurological disorder
( points in favour of a diagnosis of dissociative
disorder):
1. Sudden...
4. Occurs following a stressful event
5. Disability & distress is disproportionately lower than
the severity of symptoms
6...
 These symptoms are often constructed as child’s cry for
help in a situation of emotional trauma or stress which the
chil...
Management:
 It should be cautious & sensitive
 Should not be understood as feigning or malingering as
they are troubled...
 Ideally they should be interviewed alone
 Reassurance & positive suggestions, encouragement can
be used to make the sym...
 Family members are explained the nature of illness. The
genuineness of patient’s symptoms should be emphasized
 Parents...
 Further treatment should target at resolution of conflicts,
improvement in interpersonal relationships, developing
alter...
ACUTE ANXIETY & PANIC
Acute anxiety can occur in many psychiatric disorders & may manifest as
 Acute palpitation
 sweati...
In children panic attack can occur as a manifestation of
separation anxiety (separation from parent figure), school
phobi...
PTSD
Children who have experienced severe catastrophic
traumatic events may develop extreme fear of the specific
trauma o...
Separation anxiety
Common in young children
Join school first time or separated from attachment figures
usually mothers
...
Management:
 Rule out presence of any underlying medical illness
Child should be placed in a calm, comfortable non
threa...
Family should be reassured
In some cases hospitalization may be necessary
Supportive psychotherapy, behavior therapy & ...
ACUTE PAIN
What is pain?
Pain is subjective feeling of an unpleasant sensation that
underlies a physical disease with an a...
Psychogenic pain is often variable & shifting in nature &
is modified by situational stress & distraction
A sudden, dram...
Emergency Management:
 Not relieved by NSAIDS
 May respond to narcotic analgesic & TCAs
 Anxiolytics are not effective
Long term treatment:
Psychotherapy
Medication-SSRI
Effort should be made to understand the meaning of pain
for patient ...
If pain is manifesting only as a stress response, then stress
should be managed.
Help to acquire greater skill to handle...
NON-ACCIDENTAL INJURIES
It includes child abuse- a state of emotional, physical,
economic and sexual maltreatment meted o...
Physical abuse included injuries like cuts, bruises,
multiple fractures, burns
One should suspect sexual abuse in a chil...
One should suspect emotional abuse in a child when he
or she appears to be extremely aggrssive
Neglect is another type o...
These children are brought with complaints of physical
injury or damage that does not fit the history or details of
the a...
Munchausen syndrome by proxy:
 Mother induces or fabricates the illness in the child,
brings him over to the doctor repea...
For diagnosis it is necessary to have high degree of
suspicion.
Indications pointing towards non-accidental injuries:
1. D...
5. Hostility or anger towards the child & doctor
6. Not allowing the doctor to directly talk with the child
7. Rejecting o...
Perpetrators of abuse can be biological parents, step
parents or caregivers
Emotional & sexual abuse is more common than...
Management:
 If suspicion?
interview the child & the family members individually
Close observation of child’s behavior, ...
For child’s protection social & legal agencies need to be
involved
Give strong reassurance & support to the child
Furth...
The Protection of Children from Sexual
Offences (POCSO) Act,2012
 Provides protection from sexual assault, sexual harassm...
INHALANT RELATED DISORDER
Intoxication-
ch by apathy, diminished social & occupational functioning,
impaired judgment, im...
Management:
 Often resolves spontaneously
 Treat if there is any coma, bronchospasm, laryngospasm,
cardiac arrhythmia, t...
RECOMMENDED DRUGS FOR RAPID
TRANQUILISATION
MEDICATION DOSE ONSET OF ACTION
Olanzapine, IM 2.5-10 mg 15-30 min IM
Haloperi...
DRUG TREATMENT OF PSYCHOSIS
First choice Allow patient to chose from
Aripiprazole ( to 10 mg)/
Olanzapine ( to 10 mg)/
Ris...
DRUG TREATMENT FOR BPAD
DRUG DOSE
Aripiprazole 10 mg daily
Olanzapine 5-20 mg daily
Quetiapine 400 mg daily
Risperidone 0....
DRUG FOR DEPRESSION
Fluoxetine is the 1st line pharmacological treatment
Start with a low dose of 10 mg daily
CONCLUSION
 Psychiatric & behavioral emergencies could pose an
immediate threat to child’s life or it could be non
threat...
 A comprehensive assessment of the biological,
physical, psychosocial & family factors is necessary.
Simple supportive m...
Drugs have a very limited role accept for the treatment of
medical complications or in cases of severe psychiatric
illnes...
REFERENCES
1. Sadock B J, Sadock V A, Ruiz P. Kaplan & Sadock’s
Synopsis of Psychiatry, 11th ed. Wolters Kluwer. 2015
2. R...
Psychiatric emegencies in children
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  1. 1. PRESENTER- DR ANGSHUMANKALITA DISCUSSANT- DR NABANITA SENGUPTA CHAIRPERSON- ASSO PROF DR DEEPANJALI MEDHI PSYCHIATRIC EMEGENCIES IN CHILDREN
  2. 2. INTRODUCTION Definition: A psychiatric emergency is any disturbance in thoughts, feelings or actions for which immediate therapeutic intervention is necessary.
  3. 3. Definition: Psychiatric emergencies in children are those clinical situations where there is direct & immediate threat to the mental health of the child with or without physical harm or where the child exhibits such distressing or disruptive psychiatric or behavioral symptoms that need emergency attention
  4. 4. HISTORY  Originated in Russo-Japanese War (1904-1905)  Psychiatrist in the Imperial Russian Army treated psychiatric emergency for the first time  In 1944, US Psychiatrist introduced CRISES ORIENTED THERAPY  From 1950-1960,modern field of Emergency Psychiatry developed  1980 American Association for Emergency Psychiatry was founded
  5. 5. In a study titled ‘Psychiatric emergencies in children’ done by Christodulu et al it was found that during a 13 month period , a more than 600 visits to the ED were made for mental health concerns for children aged 2-18 yrs. Psychiatric visits constituted more than 5% of total visits In another study titled ‘Epidemiology of psychiatric related visits to emergency departments in a multicenter collaborative research pediatric network’ done by P Mahajan et al found that pediatric psychiatric related visits accounted for 3.3% of al participating ED visits
  6. 6. In another study titled ‘Disproportionately Increasing Psychiatric Visits to the Pediatric Emergency Department Among the Underinsured,’ found that over 8 years, 279 million pediatric emergency patients were seen in US EDs, of which 2.8% were psychiatric visits. The prevalence increased from 2.4% in 1993 to 3% in 2007.
  7. 7. WHO NEEDS EMERGENCY CARE? Healthy children- faced with adverse & sudden significant life events, e.g. crisis, disaster, bereavement, break down of family or child abuse; presents with serious disturbances in emotion, behavior or adjustment Clear psychiatric disorders- acute psychotic breakdown, anorexia nervosa, severe depression, conduct disorder which may be so disruptive/ distressing to child/family/society that immediate control is necessary Admitted children-Sometimes these emergencies arise for admitted children receiving inpatient treatment for medico- surgical illness where psychiatric help is sought.
  8. 8. SPECIAL ISSUES Since most children & adolescents are basically dependant on their parents, it is they & not the children themselves who perceive the situation as an emergency & seek help Occasionally older children or adolescents, or school-age children may directly report for help. It happens when they come from non-supportive environment or home
  9. 9. Apart from parents, it may sometimes be teachers, pediatricians & rarely police or other social agencies may refer the child for emergency care Depending upon the availability of services most of the cases present to general medical ER or pediatric or psychiatric departments.
  10. 10. Most emergencies occur within the family or the school setting Often give warning signals before becoming emergent Many a times, it is a chronic lingering maladjustment or disturbance that assumes such a proportion so as to be called as emergency, e.g. parental discord, anxiety, maladjustment in school etc.
  11. 11. APPROACH TO EMERGENCY PSYCHIATRIC DIAGNOSIS  Psychiatrist must perform rapid assessment with the goal of developing an immediate treatment plan that will ensure safety of the patient and others  FIRST PRIORITY:  “ Primum non nocere”: above all, do not harm- always ensure safety of all  SECOND PRIORITY:  Rule out medical etiology  Detailed informative history.  Assessment of seriousness  Stabilization of the patient if required  Physical examination including relevant lab. investigations.  Thorough mental status examination.  Developing a differential diagnosis  THIRD PRIORITY:  Appropriate treatment and disposition
  12. 12. DISORDERS THAT ARE LIKEKY TO PRESENT AS EMERGENCIES 1. Severe depression & suicide 2. Dissociative disorders 3. Anxiety & panic disorder 4. Child abuse 5. Conduct disorders 6. Post-traumatic stress disorders 7. Drug abuse 8. Anorexia nervosa 9. Psychotic disorders
  13. 13. CLINICAL MANIFESTATIONS Irrespective of the diagnosis, these disorders may present as any of the following emergent clinical problems: I. Fits or impaired consciousness II. Abnormal behavior III. Suicidal behavior, e.g. bodily harm, poisoning, drug overdose IV. Aggression & violence V. Paralysis, paresis, loss of bodily sensations VI. Refusal to eat & severe weight loss VII. Hyperventilation VIII. Acute anxiety & panic IX. Acute pain X. Non- accidental injuries & neglect
  14. 14. These presenting symptoms do not necessarily corresponds to a specific psychiatric diagnosis. These are symptoms of child’s distress or disease. Clinical evaluation addresses not merely a diagnosis in the child but also evaluates the parents & the psychosocial situation For effective intervention, management of psychopathology in the parents & the general/specific life of the child must also be attempted.
  15. 15. FITS OR IMPAIRED CONSCIOUSNESS One of the common & most dramatic presentations in ER C/c- “Fits” Ch by-symptoms of impaired consciousness, abnormal movement or behavior Episodic disturbance, lasting few min to hours
  16. 16. Often interspersed with periods of recovery Consciousness-impaired, not totally lost; may show response to deep painful stimuli Memory- partial or full preservation of memory
  17. 17. Dissociative disorder: Present as trance like states Do not remember chunk of their behavior May even exhibit psychotic phenomenon-visual/auditory hallucinations, feeling of being controlled by external forces These used to occur in children who have experienced acute or chronic stress or abuse of a severe degree. Children when overwhelmed by stress or when they feel caught in an inescapable traumatic situation spontaneously drift into dissociative states.
  18. 18. Management: Since dissociative disorder occurs in the setting of hostile, threatening & abusive environment; the clinician must determine whether the child is still under danger or threat & he/she needs to be protected from the environment. If the symptoms are severe & disruptive, hospitalization is necessary
  19. 19. Immediate relief from symptoms can be obtained by providing a reassuring nonthreatening & protective environment, isolation, establishing communication with the child & encouraging him/her to express feelings which generally are of anxiety, fear, anger or unhappiness Rapport establishment is very important Drugs have no role. If there is high evidence of anxiety then anxiolytics can be given
  20. 20. Apart from environmental intervention, such a child is treated with a variety of psychotherapeutic methods including play therapy & behavior therapy Reassurance & explanation to family members is crucial Parents need to be informed about the psychological nature of the illness in such a manner that they understand the problem in the right perspective
  21. 21. SUICIDAL BEHAVIOUR One of the common reasons Most children under 12 years of age who threaten or attempt suicide may not kill themselves. It may present in the form of bodily harm (wrist slashing), poisoning, drug overdose rarely more violent means like hanging, gunshot may be employed
  22. 22. A sad generation?  Suicide is the third leading cause of death in the 15-24 age group (follows unintentional injuries & homicide) Male gender, drug abuse, conduct disorder. For every complete suicide, there may be 50 – 200 attempts with a female preponderance.
  23. 23. Risk factors Loss of parent before the age of 12 History of parental abuse Early onset of suicidal behavior (prepubertal) predicts suicidal behavior in adolescents More than 90% of subjects who committed suicide met criteria for at least one major psychiatric diagnosis Half of these subjects had psychiatric disorder for at least two years
  24. 24. Acute psychosocial stress One in four adolescents that completed suicides show evidence of planning The most common diagnostic groups were mood disorders (52% major depression), disruptive disorders and substance abuse A child with a mood disorder is four to five times more likely to attempt suicide than a child without a mood disorder
  25. 25. NON SUICIDAL SELF INJURY NSSI
  26. 26. Non-suicidal self-injury is the direct, deliberate destruction of one’s own body tissue in the absence of intent to die.  It differs from suicide attempt with respect to intent, lethality, chronicity, methods, cognitions, reactions, aftermath, demographics and prevalence. Common forms of NSSI include cutting, burning, scratching, banging, hitting, biting and excessive rubbing.
  27. 27. Preceding the act of self-injury is a psychological experience of increasing anger, tension, anxiety, dysphoria and general distress or depersonalisation, which the person feels they cannot escape from or control. Engaging in NSSI provides a temporary release from these distressing emotions.
  28. 28. Prevalence Most studies found prevalence ranging from 15 to 25% in young adults and adolescents. Along with BPD, seen in patients with mood and anxiety disorders, eating disorders, substance misuse, conduct disorder and post-traumatic stress disorder.
  29. 29. NSSI and Suicidality NSSI is the strongest predictor of future suicide attempts in adolescents High levels of depression, suicidal ideation and hopelessness characterise participants who engage in either NSSI or suicide attempt.
  30. 30.  Assessment must refer to the totality of the event & circumstances surrounding the act-severity & persistence of suicidal ideation or intent, lethality, underlying depression or conduct disorder, drug abuse, prior suicidal attempt, f/h of suicide, access to weapons etc  Detailed psychiatric history, MSE & assessment of family functioning must be done
  31. 31. Management  Hospitalization- initially in medical/surgical unit.  Psychiatric hospitalization-high risk for suicide, evidence of psychosis & depression, persistence suicidal ideation, prior suicidal attempt, chaotic or dysfunctional family  High surveillance for repeated attempt must be maintained for a few days after the current attempt  Medication for primary psychiatric disorder if present in the child
  32. 32. Characteristics of psychiatric units  Ground floor  Easily observable rooms.  Weapons, toxic substances, electrical devices- made out of reach for patients.  Hanging- 10% occur in hospitals. Restrict access to means of hanging.  Unfortunately, suicides still may occur unexpectedly.
  33. 33. AGGRESSIVE & VIOLENT BEHAVIOUR  May be a manifestation of underlying psychotic disorder like schizophrenia or BPAD, ADHD, delirium or seizures.  May be a reaction to interpersonal difficulties with parents, peers or teachers  Children or adolescent who have low frustration tolerance, poor impulse control, underlying personality difficulties of borderline or antisocial type, conduct disorder, oppositional defiant disorder or drug abuse, etc. might show aggression or violence
  34. 34.  The first task in such an emergency is to assess the risk & safety of the child & of those around him  Do’s 1. Protect yourself 2. Unarm the patient 3. Keep the doors open 4. Keep others near you 5. Do restrain if necessary 6. Wear white coat & ID tag 7. Assert authority 8. Show concern, empathy, establish rapport & assure the patient 9. Encourage him/her to speak about his anxiety & minimize fear & make him/her calm
  35. 35. Don’ts 1. Do not keep any potential weapon near the patient 2. Do not sit with back to patient 3. Do not wear neck tie or jewellery 4. Do not keep any provocative family member or friend near the patient 5. Do not confront 6. Do not sit close to the patient
  36. 36.  During this process, a quick MSE should be done specially looking for signs of major psychiatric illness.  Presence of abnormal speech, irrelevant talk, delusion, hallucination-psychosis  Gross disorientation to time, place, memory impairment, gross incoherence of speech, confusion, ill organized acts of violence, sphincter incontinence- CNS pathology
  37. 37. Management: 1. Physical restraint, if necessary 2. Oral or may be parenteral ( if uncooperative) medication in form of IM or IV inj haloperidol, chlorpromazine or lorazepam is recommended for quick relief 3. Hospitalization- to tide over the crisis
  38. 38.  Methods of physical restraint 1. Use judiciously for the minimum period of time 2. Explain to the patient the reason for restraint 3. Should be done by trained personnel 4. Use leather restraint- safest & surest. Soft cotton cloths, if available 5. At lest five persons are usually required to restraint 6. Restraint is done one limb at a time, while the other limbs are held firmly by others 7. Restraint in arms are placed in such a way that IM or IV inj or fluid can be given easily
  39. 39. 8. Patient should be restrained with legs spread eagled & one arm restrained to one side & other arm restrained over patient’s head 9. Head is raised slightly 10. Intoxicated patient should be restraint in the left lateral position 11. A staff member should always be visible & reassuring the patient. 12. Assess periodically about removal of restraint 13. Remove restraint one limb at a time 14. Vitals should be monitored periodically 15. Maintain documentation: Reason, treatment, response
  40. 40. SECLUSION  INDICATION Therapeutic isolation for limiting provocative environmental stimulation (Agitated patient) e.g. partitioned area, unlocked time out room  CONTRAINDICATION Patient with suicidal risk, MR, seizure disorder, drug overdose, delirium, demented, psychosis
  41. 41. Seclusion cell in LGBRIMH,Tezpur (NOT practised now a days)
  42. 42.  In certain situations where aggression & violence has occurred d/t conflict between child & parent, a gentle & calm approach, allowing the child to talk about his difficulties brings down the aggression & medication is not needed.  Assessment is also made of the degree to which the child appears or feels in control of his emotion & behavior.  Many children can say that they are feeling alright & can control themselves.
  43. 43.  They can be handled psychologically where a communication is established with a therapist & an understanding is reached to resolve the issues during therapy sessions  This emergency management must be followed by longer term treatment with a psychiatrist
  44. 44. ABNORMAL BEHAVIOUR Sudden appearance of abnormal behavior psychomotor excitement Stupor irrelevant speech abnormal motor movements inappropriate acts amnesias ( partial or total loss of memory) occurring in the background of a psychiatric disorder or emotional stress constitutes an emergency.
  45. 45. Management:  Level of consciousness must be ascertained  Neurological assessment must be done- to r/o neurological causes  Sudden abnormal behavior can occur in acute onset functional psychosis, e.g. schizophrenia, affective disorder or acute & transient psychotic disorder. In these cases delusion, hallucination, gross psychomotor excitement, stupor etc. may be present
  46. 46.  Often schizophrenia & affective disorders takes days or weeks to develop. In some cases the onset of psychosis may be abrupt particularly when there is acute stress preceding the onset & in such cases psychosis is brief & short lasting  Sometimes drug intoxication or withdrawal might present as acute psychosis  Detailed history is sufficient to clarify the diagnosis
  47. 47.  Sometimes abnormal behavior is not of psychotic proportions or there are no psychotic symptoms. It can occur following acute emotional stress as in dissociative disorder or PTSD  Such a child is handled with psychological support in the form of reassurance, ventilation & catharsis, encouragement & positive guidance.  Change in the environmental circumstances like removal of the child from stress situation may be necessary sometimes.
  48. 48.  Medication may be given as necessary to counteract manifest anxiety or depression or psychotic behavior  Patient who shows continuous or recurrent abnormal behavior need to be admitted
  49. 49. REFUSAL TO EAT & SEVERE WEIGHT LOSS  Rare, but life threatening emergencies  Usually encountered in adolescent females.  Anorexia nervosa - refusal to eat, anorexia & persistent vomiting, wt. loss
  50. 50.  Patients go into a medical emergency due to complications of starvation: 1. Dehydration 2. Dyselectrolytemia 3. Hypoglycemia 4. Cardiac arrhythmia 5. Vomiting 6. Abdominal pain  Mortality in severe cases is 15-20%
  51. 51.  Bulimia nervosa- Sometimes patients goes into bouts of overeating followed by extreme steps to control body weight like vomiting (often induced), purging, starvation, use of drugs, etc.  It may also present with Dyselectrolytemia, muscle weakness, seizure etc.
  52. 52. Management: Hospitalization Immediate assessment of the functioning of vital organs like- ECG, CBC, S. electrolytes, RFT, LFT, urinanalysis Often highly resistant to treatment & may have to be admitted against patient’s wish Any serious medical complication to be managed accordingly
  53. 53.  Psychological assessment& psychiatric evaluation  Family members are explained the seriousness of the disease  Further treatment in the form of intensive psychotherapy, behavior therapy, family therapy is carried out in psychiatric ward or OPD
  54. 54. PARALYSIS, PARESIS, LOSS of BODILY SENSATIONS Sometimes patients are brought to emergency with sudden development of weakness of limbs or paralysis or loss of superficial sensations (pain, touch, temperature) or of special sensations like loss of vision, hearing, smell or taste More dramatic presentations like aphonia, mutism, Agraphia, paraesthesias, etc. are not uncommon. These symptoms can be easily distinguished from true neurological symptoms on the basis of a good history & clinical examination
  55. 55. Points against a diagnosis of neurological disorder ( points in favour of a diagnosis of dissociative disorder): 1. Sudden development of these symptoms in absence of any h/o medical/neurological illness preceding it 2. Without any evidence of concomitant disease 3. Symptoms do not follow the known pattern of distribution, based on anatomical & functional segments of the CNS
  56. 56. 4. Occurs following a stressful event 5. Disability & distress is disproportionately lower than the severity of symptoms 6. Functions underlying the symptoms is preserved which can be demonstrated by encouraging the child, giving positive suggestions or by sudden maneuver when the child is inattentive
  57. 57.  These symptoms are often constructed as child’s cry for help in a situation of emotional trauma or stress which the child is trying to avoid or resolve.  Seen in children who have relatively low IQ & who come from lower SES families who have limited resource & are unable to handle their life problems in a more adaptive manner
  58. 58. Management:  It should be cautious & sensitive  Should not be understood as feigning or malingering as they are troubled by emotional difficulties  Approach should be empathic & supportive-to bring out the underlying cause of emotional distress
  59. 59.  Ideally they should be interviewed alone  Reassurance & positive suggestions, encouragement can be used to make the symptoms disappear  Once the symptom is removed the family feels reassured
  60. 60.  Family members are explained the nature of illness. The genuineness of patient’s symptoms should be emphasized  Parents are explained the need for establishing a communication with the child where the child can express his desires & needs without fear.  They should understand the child’s emotion & their thoughts need to be respected & duly considered
  61. 61.  Further treatment should target at resolution of conflicts, improvement in interpersonal relationships, developing alternate & more adaptive ways of handling stress  Drugs have no role, but can be used as placebo for quick removal of symptoms  Main mode of treatment is psychotherapy
  62. 62. ACUTE ANXIETY & PANIC Acute anxiety can occur in many psychiatric disorders & may manifest as  Acute palpitation  sweating,  Trembling  Chocking  Dizziness  Numbness  Tingling  Hyperventilation  Fainting  Acute chest pain All these symptoms may build up gradually or may start suddenly & remain for a variable period of time
  63. 63. In children panic attack can occur as a manifestation of separation anxiety (separation from parent figure), school phobia or sexual abuse Sometimes symptoms like Derealization or depersonalization, fear of dying, light headedness, unsteadiness, nausea or abdominal distress may also be seen All these symptoms pertaining to emotional, cognitive & somatic domains characterize underlying anxiety which when acute & intense may be brought to ED
  64. 64. PTSD Children who have experienced severe catastrophic traumatic events may develop extreme fear of the specific trauma or of the situations or persons associated with the traumatic event Child may be terrified, hallucinate, re-live traumatic situations, have illusions or dreams about it  It can be easily recognized by h/o trauma & the characteristic symptoms reflecting the trauma
  65. 65. Separation anxiety Common in young children Join school first time or separated from attachment figures usually mothers Extreme fear or worry about well being attachment figure Headache, stomachache, nausea, vomiting When first seen in adolescence it indicates presence of depressive & anxiety disorder or psychosis
  66. 66. Management:  Rule out presence of any underlying medical illness Child should be placed in a calm, comfortable non threatening environment & reassured Ask to take regular, slow & deep breathes For quick relief anxiolytics can be prescribed
  67. 67. Family should be reassured In some cases hospitalization may be necessary Supportive psychotherapy, behavior therapy & play therapy are very useful In separation anxiety & PTSD- sertraline can be added to psychotherapy
  68. 68. ACUTE PAIN What is pain? Pain is subjective feeling of an unpleasant sensation that underlies a physical disease with an associated emotional upset Very common presentation in ED To differentiate between somatic pain & psychogenic pain a thorough physical exam & clinical history should be taken in every case
  69. 69. Psychogenic pain is often variable & shifting in nature & is modified by situational stress & distraction A sudden, dramatic onset of pain in absence of a known h/o physical disorder, occurring in stressful situation or in the background of dissociative disorder, anxiety, depression & histrionic behavior is likely to be a psychogenic pain
  70. 70. Emergency Management:  Not relieved by NSAIDS  May respond to narcotic analgesic & TCAs  Anxiolytics are not effective
  71. 71. Long term treatment: Psychotherapy Medication-SSRI Effort should be made to understand the meaning of pain for patient in the background of his/her emotional upsets & life circumstances If there is evidence of underlying anxiety, depression, hypochondriasis, etc. then it should be treated by psychiatrist
  72. 72. If pain is manifesting only as a stress response, then stress should be managed. Help to acquire greater skill to handle emotions or life stress Biofeedback, yoga, meditation
  73. 73. NON-ACCIDENTAL INJURIES It includes child abuse- a state of emotional, physical, economic and sexual maltreatment meted out to a person below the age of eighteen There is a section of children who are more vulnerable for child abuse. They are 1) children who grew up in very poor family, 2) children with divorced parents, 3) children with highly stressed caregiver, 4) differently abled children.  There are four major categories of child abuse: Physical abuse, Psychological/emotional abuse, Sexual abuse & Neglect
  74. 74. Physical abuse included injuries like cuts, bruises, multiple fractures, burns One should suspect sexual abuse in a child when the child is having difficulty in walking or sitting,stained or bloody underwear or whent here is pain, itching, redness, discharge,bruise or other injuries in private parts.
  75. 75. One should suspect emotional abuse in a child when he or she appears to be extremely aggrssive Neglect is another type of child abuse. It should be suspected when there is lack of basic food and clothing, inappropriate child hygiene ,lack of appropriate supervision,lack of education,lack of medical treatment or medication for a serious illness or residing in an inappropriate/dangerous living environment . These children may have delayed growth and developement. In infants it can present as failure to thrive.
  76. 76. These children are brought with complaints of physical injury or damage that does not fit the history or details of the accident given by attendants. Abuse is suspected by the clinician
  77. 77. Munchausen syndrome by proxy:  Mother induces or fabricates the illness in the child, brings him over to the doctor repeatedly May present with many serious & sinister symptoms like poisoning, seizures, bleeding from various orifices, fever, injuries etc. (Meadow 1989)
  78. 78. For diagnosis it is necessary to have high degree of suspicion. Indications pointing towards non-accidental injuries: 1. Delay in seeking medical help 2. History & clinical examination does not add up 3. Inadequate concern or anxiety toward the child 4. Child may appear frightened of his attendants, withdrawn
  79. 79. 5. Hostility or anger towards the child & doctor 6. Not allowing the doctor to directly talk with the child 7. Rejecting or refusing treatment 8. DAMA/LAMA
  80. 80. Perpetrators of abuse can be biological parents, step parents or caregivers Emotional & sexual abuse is more common than physical abuse May be acute/ chronic abuse
  81. 81. Management:  If suspicion? interview the child & the family members individually Close observation of child’s behavior, parent-child relationship In all cases child’s safety & protection are foremost concern
  82. 82. For child’s protection social & legal agencies need to be involved Give strong reassurance & support to the child Further psychiatric intervention involves improving the parent-child relationship, improving parenting skills & attitude of parents; help to control impulses; problem solving skills
  83. 83. The Protection of Children from Sexual Offences (POCSO) Act,2012  Provides protection from sexual assault, sexual harassment and pornography  Section 21 of the Act, requires mandatory reporting of cases of child sexual abuse, hence the onus is on citizens, that is parents, doctors and school personnel to report cases to the law enforcement authorities (Special Judicial Police Unit or Local Police).  Failure to report a suspicion of child abuse punishable with imprisonment of six months or with fine or both. Those running institutions have greater punishment which may extend to one year or with fine or both.  This provision also focuses on police personnel who refuse to register child abuse cases.
  84. 84. INHALANT RELATED DISORDER Intoxication- ch by apathy, diminished social & occupational functioning, impaired judgment, impulsive or aggressive behavior often accompanied by nausea, anorexia, nystagmus, diminished reflexes & diplopia. Patient may also come in stuporous & unconscious state or amnesia for a brief period Clinician can sometime identify a recent user by rashes round nose & mouth, unusual breath odor, residue of the substance in body & cloths, irritation in eyes, throat, lungs & nose
  85. 85. Management:  Often resolves spontaneously  Treat if there is any coma, bronchospasm, laryngospasm, cardiac arrhythmia, trauma or burns.  Sedative drugs are contraindicated  Primary care- reassurance, support, attention to vitals & consciousness  Street outreach & extensive social service support, family support is necessary
  86. 86. RECOMMENDED DRUGS FOR RAPID TRANQUILISATION MEDICATION DOSE ONSET OF ACTION Olanzapine, IM 2.5-10 mg 15-30 min IM Haloperidol 0.025-0.075mg/kg/dose (max 2.5mg) IM >12 yrs 2.5-5mg 20-30 min IM Lorazepam 0.05-0.1 mg/kg/dose IM 20-40 min Midazolam 0.1- 0.15 mg/kg 10-20 min IM 1-3 min IV Diazepam, IV 0.1 mg/kg/dose slow IV Max 40 mg total <12 yrs 60 mg>12 yrs 1-3 min Ziprasidone 10-20 mg 15-30 min IM
  87. 87. DRUG TREATMENT OF PSYCHOSIS First choice Allow patient to chose from Aripiprazole ( to 10 mg)/ Olanzapine ( to 10 mg)/ Risperidone (to 3 mg) Second choice Switch to alternate drug Third choice Clozapine
  88. 88. DRUG TREATMENT FOR BPAD DRUG DOSE Aripiprazole 10 mg daily Olanzapine 5-20 mg daily Quetiapine 400 mg daily Risperidone 0.5-2.5 mg daily Valproate Titrate to above 50 mg/l
  89. 89. DRUG FOR DEPRESSION Fluoxetine is the 1st line pharmacological treatment Start with a low dose of 10 mg daily
  90. 90. CONCLUSION  Psychiatric & behavioral emergencies could pose an immediate threat to child’s life or it could be non threatening. In all the situations, an emergency is an indication of the breakdown of an already compromised psychological, social & family functioning. It also serves as the contact point for initiation of steps for remedy & restoration of dysfunction.
  91. 91.  A comprehensive assessment of the biological, physical, psychosocial & family factors is necessary. Simple supportive measures like ventilation, catharsis, reassurance & expression of regard for the patient is very helpful
  92. 92. Drugs have a very limited role accept for the treatment of medical complications or in cases of severe psychiatric illness like psychosis, depression or anxiety Psychiatric hospitalization may be necessary to tide over the crisis. Psychiatric consultation in emergency sets the tone for subsequent prolonged intervention for the treatment of the basic pathology
  93. 93. REFERENCES 1. Sadock B J, Sadock V A, Ruiz P. Kaplan & Sadock’s Synopsis of Psychiatry, 11th ed. Wolters Kluwer. 2015 2. Rutter M, Bishop D, Pine D, Scott S, Stevenson J, Taylor E, Thapar A. Rutter’s Child & Adolescent Psychiatry, 5th ed. Blackwell Publishing Ltd. 2008 3. Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines in Psychiatry, 11th ed. Wiley-Blackwell.2012 4. Semple D, Smyth R. Oxford Handbook of Psychiatry, 3rd ed. Oxford. 2013 5. Malhotra S. Clinical Assessment & Management of Childhood Psychiatric Disorders, 2nd ed. CBS Publishers & Distributors Pvt Ltd. 2013 6. Vyas JN, Ahuja N. Textbook of Postgraduate Psychiatry-vol 2, 2nd ed. JAYPEE.1999
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ppt on psychiatric emergencies in children

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