Mostly it Covers all Emergencies in Psychiatry.

1. MR. NITHIYANANDAM, MSN, II YEAR,
CON, MTPG & RIHS.

2.  Emergency: It is an unforeseen combination of circumstances which
calls for an immediate action.
 Crisis: A situation that presents a challenge to the patient ,family
and for community .
 Stupor: It is a condition where the patient is conscious but there is
non-responsiveness to the surroundings.
 Violence: It is physical aggression inflicted by one person to another
.
 Suicide: It is the intentional taking of one’s own life in a culturally
non – endorsed manner.
 Bewilderment:Confusion resulting from failure to understand.
TERMINOLOGIES

3. 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.
INTRODUCTION

4.  The initial approach to the patient should be warm, direct and
concerned.
 A quick evaluation to identify the nature of the condition and to
institute care on the basis of seriousness is essential.
 The emergency staff should have basic knowledge of handling
psychiatric emergencies.
 Medicolegal cases need to be registered separately and informed to
the concerned officer.
 Hospital security must be adequate to control violent and dangerous
patients.
INITIAL APPROACHES DURING EMERGENCY

5.  History and clinical findings should be recorded clearly in the
emergency file.
 Patient’s condition and plans of management should be explained in
simple language to the patient and family members.
…CONTD/-

6.  Between 1992 and 2001 there were 53 million mental health-related
emergency department contacts in the United States,
 An increase from 4.9% to 6.3% of all emergency department visits,
and an upswing from 17.1–23.6 visits per 1,000 of the US population
during this period.
 One study estimated that 135,000 emergency psychiatric
assessments are made each year in New York State hospitals alone.
 Due to frequently inadequate alternatives, emergency departments
and psychiatric emergency services (PESs) have become the primary
acute care settings where patients seek mental health care in the
US.
PREVALENCE OF PSYCHIATRIC
EMERGENCIES

7. 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

8.  Certain condition or stressor predisposes the client family
members t seek immediate intervention as they feel more
discomfort.
 Disharmony between client and his environment
 Sudden unexpected disorganization in person
 Unable to cope with the stressful situation or family in
handling the stressors
CHARACTERISTICS OF PSYCHITRIC
EMERGENCIES

9.  Tense and chaotic atmosphere.
 Time constraint.
 Impersonal and transient doctor-patient relationship.
 Primary physician is not a psychiatrist.
 Antipathy feeling towards psychiatrist by emergency staff.
 Lack of confidence and faith by relatives of patient in psychiatrists.
 Often used by non-emergency cases as an easy way to be in contact
with psychiatric services, leading to loss of valuable time.
 Often viewed by psychiatrist as a non-rewarding job.
PROBLEMS IN EMERGENCY ROOM

10.  Acute Onset
 Old Age
 First Episode
 Non – Auditory Hallucinations
 Disorientation / Confusion
 Memory Impairment
 Catatonic State
 Neurological Symptoms like Unconsciousness, Seizures, Head Injury,
and Visual Problems.
FEATURES INDICATING A POSSIBILITY OF MEDICAL
ILLNESS

11.  Quiet and comfortable room, that insulates both the patient and the
therapist from the hectic atmosphere of the ER, with a 'panic
button' and an easy access to door.
 Provision of round-the-clock holding unit, that would make
unhurried assessment and management possible.
 Staffing arrangements should be made in a manner that ensure the
continuity of care and allow for the development of expertise in the
delivery of emergency services.
 Regular availability of senior staff for supervision and teaching.
GUIDELINES FOR EFFECTIVE AND QUALITY
EMERGENCY CARE

12.  The nature and availability of support system and capacity of the
patient to use it.
 Dangerousness.
 Psychiatric history and current psychiatric status, including
patient’s ways of coping with similar stressors previously.
 Ability to care for oneself.
 Motivation and capacity to participate in the treatment process.
 The request(s) of patient and family.
 Medical status.
EVALUATION APPROACH FOR EMERGENCY
PSYCHIATRIC TREATMENT

13. 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.
SUICIDE ATTEMPTS AND
SUICIDAL THOUGHTS

14. Psychiatric Disorders:
 Major depression
 Schizophrenia
 Drug or alcohol abuse
 Dementia
 Delirium
 Personality disorder
Physical Disorders:
 Patients with incurable or painful physical disorders like, cancer and
AIDS.
AETIOLOGY

15. Psychosocial Factors:
 Failure in examination
 Dowry harassment
 Marital problems
 Loss of loved object
 Isolation and alienation from social groups
 Financial and occupational difficulties
…CONTD/-

16.  Age:
 Males above 40 years of age
 Females above 55 years of age
 Sex:
 Men have greater risk of completed suicide
 Suicide is three time 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
RISK FACTORS FOR SUICIDE

17. Certain psychiatric disorders where the patient may develop suicidal
tendencies include:
Major depression: This is one of the commonest conditions associated
with a high risk of suicide. Suicide in a major depressive episode is
due to pervasive and persistent sadness; pessimistic cognitions
concerning the past, present and future; delusions of guilt,
helplessness, hopelessness and Worthlessness; and derogatory voices
urging him to take his life. The risk of suicide is more when the acute
phase has passed and the characteristic psychomotor retardation has
improved. This is so because the patient has more energy to carry out
his suicidal plans now, though he might have been harbouring them
for quite some time.
SUICIDAL TENDENCY IN PSYCHIATRIC WARDS

18. Schizophrenia: The major risk factors among schizophrenics include
the presence of associated depression, young age and high levels of
premorbid functioning (especially during college education). People in
this risk group are more likely to realize the devastating significance
of their illness more than other groups of schizophrenic patients do,
and see suicide as a reasonable alternative.
Mania: Manic patients may occasionally commit suicide. This is usually
the result of grandiose ideation. The patient may believe that he is a
great person, or wish to prove his supernatural powers. With this
intent in mind, he may carry out some dangerous activity that can cost
him his life.
…CONTD/-

19. Drug or alcohol abuse: Suicide among alcoholics can be due to
depression in the withdrawal phase. Also, the loss of friends and
family, self-respect, status, and a general realization of the havoc
alcohol has created in his life can cause the individual to Wish to die.
Personality disorder: Individuals with histrionic and borderline traits
may Occasionally attempt suicide.
Organic conditions: Conditions such as delirium and dementia due to
Changes of mood like anxiety and depression may also induce suicidal
tendency.
…CONTD/-

20. 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.
MANAGEMENT

21. Monitoring the patients 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.
 Remove straps and clothing such as belts, neckties.
 Do not allow the patient to bolt his door on the inside, make sure
that somebody accompanies him to the bathroom.
…CONTD/-

22.  Patient should be kept in constant observation and should never be
left alone.
 Have good vigilance especially during morning hours.
 Spend time with him, talk to him, and allow him to ventilate his
feelings.
 Encourage him to talk about his Suicidal Plans / methods.
 lf suicidal tendencies are very severe, sedation should be given as
Prescribed.
…CONTD/-

23.  Encourage verbal communication of suicidal ideas as well as his /
her fear and depressive thoughts. A 'no suicidal’ pact maybe signed,
which is a written agreement between the patient and the nurse,
that patient 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.
…CONTD/-

24.  Assess for vital signs, check airway, if necessary clear airway.
 If pulse is weak, start IV fluids.
 Turn patient's head and neck to one side to prevent regurgitation
and swallowing of vomitus.
 Emergency measures to be instituted in case of self-inflicted injuries.
MANAGEMENT OF ATTEMPTED SUICIDE IN THE
INPATIENT UNIT

25.  Transfer the patient to medical centre immediately.
 If there is no evidence of life leave the body in the same
position/room in which it was found (move the patient in case
suicide from a common living area for example, dining room or TV
room)
 In case the patient has attempted suicide by jumping, do not leave
the body in a place which is visible to other patients of the ward
 Inform authorities, record the incident accurately
 Contact local guardian and inform them
 Place an attendant outside the room where the body is kept
MANAGEMENT OF SHOCK

26.  Once the patient is transferred to mortuary or police custody clean
the place with disinfectant solution
 Hand over the patients properties to the concerned authorities/
relatives
 Carry out the institutional formalities for death certificate
 The senior staff should discuss the incident in detail with all the
staff and reassure them.
 The discussion should include possible lapses and preventive
measures that need to be undertaken the Care for other patients
should include the following:
Transfer all the patients away from the incident location.
…CONTD/-

27. Keep the patients in the centre engaged by games and other
recreational activities.
Serve food and medication to the patients earlier than schedule.
A Observe for any change in the behaviour.
Inform the psychiatrist.
…CONTD/-

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

29.  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 10-20
mg IV; haloperidol 10-20 mg; chlorpromazine 50-100 mg IM.
 Once the patient is sedated, collect history carefully from relatives;
rule out the possibility of organic pathology. ln particular check for
history of convulsions, fever, recent intake of alcohol, fluctuations
of consciousness.
MANAGEMENT

30.  Carry out complete physical examination
 Send blood specimens for Haemoglobin, total cell count, etc.
 Look for evidence of dehydration and malnutrition. lf there is
severe dehydration, IV drip may be started.
 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.
…CONTD/-

31.  Stay with the patient as hyperactivity increases to reduce anxiety
level and foster a feeling of security.
 Redirect violent behaviour 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.
…CONTD/-

32. 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. Il 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.
…CONTD/-

33.  Be sure that the patient has no weapons in his profession 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.
 Keep something like a pillow, mattress or blanket wrapped around
arm between you and the weapon.
 Distract the patient momentarily to remove the weapon (throwing
water in the patient's face, yelling, etc.,)
 Give Prescribed antipsychotic medications.
…CONTD/-

34. 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, paraesthesia,
chills or hot flushes
Management:
 Give reassurance first.
 Search for causes.
 Diazepam 10 mg or lorazepam 2 mg may be
administered.
PANIC ATTACKS

35. 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, stenotypes, etc.,
CATATONIC STUPOR

36. Management:
 Ensure patent airway
 Administer IV fluids
 Collect history and perform physical examination
 Draw blood for investigations before starting my treatment
 Other care is same as that for an unconscious patient.
…CONTD/-

37. Grief is a reaction of an individual to a significant
loss.
Factors affecting grief reaction:
 Abruptness of loss.
 Extent of loss.
 Preparation for loss.
 Significance of the lost person (object) to the
individual.
 Past experience of grief.
 Cultural background.
 Personality traits.
GRIEF

38. The clinical features of uncomplicated grief are sadness,
insomnia, poor appetite, loss of interest, guilt and death wish.
Stages:
 Hours to days: Shock and disbelief.
 Weeks to months: Anger, resentment, depression.
 Six months to a year: Acceptance of reality
UNCOMPLICATED GRIEF

39. Management:
 Evaluation to find out any primary psychiatric disorder.
 Crisis intervention: Patient is encouraged to talk about his feeling
concerning the deceased in a private room. Reassurance is given
that this is a normal process and will subside on its own. Do not
discourage expression of anger or hostility towards either the
deceased or the physician.
 Pharmacotherapy: Avoid drug treatment, as far as possible.
Prescribe night time sedatives on an as needed (SOS) basis.
 Referral to psychiatric services for primary psychiatric condition, if
necessary.
…CONTD/-

40. It is characterized by suicidality, prolonged functional
impairment, marked psychomotor retardation, morbid preoccupation
with feelings of worthlessness, or unresolved uncomplicated grief.
Management:
 Facilitate grieving process by helping the patient to remember the
deceased and the nature of relationship
 Brief supportive psychotherapy.
 Hospitalization, if required.
COMPLICATED GRIEF

41. 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
HYSTERICAL ATTACKS

42. All presentations are marked 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.
MANAGEMENT

43. These are characterized by disturbed feelings
and behaviour occurring due to overwhelming
external stimuli.
Management:
 Reassurance
 Mild sedation if necessary
 Allowing the patient to ventilate his/her feelings
 Counselling by an understanding professional
TRANSIENT SITUATIONAL
DISTURBANCES

44. 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 4mg IV, followed by oral
administration.
 Maintain fluid and electrolyte balance.
 Reassure patient and family.
DELIRIUM TREMENS

45. 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.
EPILEPTIC FUROR

46. 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-
potency compounds.

47. Management:
The drug should be 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.

48. 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.

49. Management:
 Administer Oxygen
 Start IV line
 Assess for cardiac arrhythmias
 Refer for haemodialysis
 Administer anticonvulsants
…CONTD/-

50. VICTIMS OF 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,
flood, riots and terrorism, Anger, frustration, guilt,
numbness and confusion are common features in these
people.
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.

51.  Critical incident debriefing includes five phases: Fact, thought,
reaction, reaching and Re-entry:
 In the fact phase, each participant is involved to share his or her
perception of the incident. The group members describe the
incident, new information and pieces of information are integrated
into a more understandable whole.
 The thought phase, builds on this information by asking participants
to reflect the incident and to share what they were feeling
personally during different times of the crisis.
…CONTD/-

52.  In the reaction phase, participants are asked to evaluate the impact
of the emotional aspects of the incident (for example, what was the
worst part of the incident for you). Previously not discussed and less
acceptable feelings are allowed to emerge in a safe environment.
Knowing that other people are experiencing the same feelings makes
them realize that these feelings are normal behavioural responses to
abnormal circumstances, and this brings a lot of relief to people who
are under intense stress. Participants discuss stress related symptoms
they had during the incident or are experiencing currently.
…CONTD/-

53.  The teaching phase, focuses on specific cognitive, emotional and
spiritual strategies to reduce stress and ways to enhance group
support.
 In the final re-entry phase, the facilitator encourages questions and
summarizes the process, Finally individuals are referred to further
counselling if needed.
…CONTD/-

54.  Group therapy
 In selected cases benzodiazepines are prescribed to reduce anxiety
and induce sleep
 Referral to mental health service, if required
 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.
 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
…CONTD/-

55. Rape is a perpetuation of an act of sexual
inter- course with a female against her will and
consent.
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.
RAPE VICTIM

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

57. Emergency room repeaters:
Normally 3% of patients account for about 20% of the psychiatric
visits in a given year.
Management:
 Make a consistent and unified approach to explore
 the emergency problem(s) and manage it.
 Do not entertain the case, in case of non-emergency
SPECIAL POPULATIONS

58. Young adult chronic patients:
These Patients are often brought to ER by families because of
decompensation following discharge and discontinuation of
medication.
Management:
 Direct communication with the primary treating team
 Referral to appropriate program.
…CONTD/-

59. …CONTD/-
Elderly Patients:
Elderly patients seek ER services less than their younger
counterparts. The commonest presenting complaint is peculiar or
disturbing behaviour for six months or more. The common diagnoses
are major depressive disorder, Substance abuse and medication side
effects.
Management:
 Treat the patients presenting problem
 Family consultation.

60. …CONTD/-
Children and adolescents:
Family crisis often precipitates an emergency in this group.
Suicide attempts, gestures and ideation occur about twice as often as
in an adult emergency population.
Management:
 Rapid intervention is needed, focusing on the presenting problem.
 Deal with family issues attributable to emergency