PSYCYHIATRIC EMERGENCY

The Star of Life,

representing emergency medical services

Dr. H. Abdulllah Shahab, Sp.KJ

Bag. IKJ FK Unsri - Departemen Jiwa RSMH
 INTRODUCTION

 DEFINITION
Emergency Psychiatry / Psychiatric Emergency is the
clinical application of
psychiatry in emergency settings.

Psychiatric Emergency Services (PES) is a 24-hours a day

service provided for psychiatric emergencies for both
voluntary and involuntary patients
  CONDITIONS REQUIRING
INTERVENTIONS

1. Suicide
2. Substance Abuse
3. Anxiety/Panic
4. Disaster
5. Abuse, physical/sexual
6. Psychosis
7. Violence or
8. other rapid changes in behaviour
 PSYCHIATRIC EMERGENCY SERVICES
(PES)

 The facilities, sometimes housed in a psychiatric

hospital, psychiatric ward, or emergency room, provide
immediate treatment to both voluntary and involuntary
patients
 The treatment team features a multidisciplinary
approach, with professionals from psychiatry, social
work, psychiatric nursing, chemical dependency and
community mental health
 Clinical Staff consists of:

 Psychiatrists
 Emergency Physicians
 Mental Health associates: Medicine, Nursing,
Psychologist, Social Work
 Registration/Admitting clerks
 Services include:
 Diagnostic psychiatric evaluations for the presence of a
mental illness.
 Assessment and reassessment.
 If necessary, admission to inpatient facility.
 Crisis intervention related to a psychiatric illness.
 Linkage and referral to ongoing mental health services.
 Referrals may be given for medical, dental, legal, social,
or substance abuse services.
 Ambulatory detoxification services are provided by
referral only in conjunction with enrollment in an
intensive treatment program.
 SERVICE PROCEDURE

PATIENT

TRIAGE

MINOR AND SERIOUS LIFE-THREATENING

SYMPTOMS SYMPTOMS

ASSESSMENT CRISIS STABILIZATION

DISPOSITIONAL
OPTION

TREATMENT PLANNING
 1. Suicide attempts and suicidal thoughts

 As of 2000, the World Health Organization estimated one

million suicides each year in the world.
 predict acts of violence patients may commit against
themselves (or others), even though the complex factors
leading to a suicide stem from so many sources, including
psychosocial, biological, interpersonal, anthropological and
religious
 use any resources available to them to determine risk
factors, make an overall assessment, and decide on any
necessary treatment.
2. Substance abuse, dependence, intoxication
 Psychoactive drugs
- intoxication,
Alcohol: idioyncratic intoxication could occur in some individuals even
after the consumption of relatively small amounts of alcohol. Episodes
of this impairment usually consist of confusion, disorientation,
delusions and visual hallucinations, increased aggressiveness, rage,
agitation and violence.
Acting as a depressant of the central nervous system, the early effects of
alcohol are usually desired for and characterized by increased
talkativeness, giddiness, and a loosening of social inhibitions. Besides
considerations of impaired concentration, verbal and motor
performance, insight, judgment and short term memory loss which
could result in behavioral change causing injury or death, levels of
alcohol below 60 milligrams per deciliter of blood are usually
considered non-lethal.
Chronic alcoholics may also suffer from alcoholic hallucinosis, wherein
the cessation of prolonged drinking may trigger auditory
hallucinations. Such episodes can last for a few hours or an entire week.
Alcohol……….
 However, individuals at 200 milligrams per deciliter of blood
are considered grossly intoxicated and concentration levels at
400 milligrams per deciliter of blood are lethal, causing
complete anesthesia of the respiratory system.
 Patients may also be treated for substance abuse following the
administration of psychoactive substances containing
amphetamine, caffeine, tetrahydrocannabinol, cocaine,
phencyclidines, or other inhalants, opioids, sedatives,
hypnotics, anxiolytics, psychedelics, dissociatives and
deliriants
 the clinician must determine substances used, the route of
administration, dosage, and time of last use to determine the
necessary short and long term treatments. An appropriate
choice of treatment setting must also be determined.
 3. Anxiety / Panic

 Feelings of anxiety may present in different ways from

an underlying medical illness or psychiatric disorder, a
secondary functional disturbance from another
psychiatric disorder, from a primary psychiatric
disorder such as panic disorder or generalized anxiety
disorder, or as a result of stress from such conditions as
adjustment disorder or post-traumatic stress disorder.
Clinicians usually attempt to first provide a "safe
harbor" for the patient so that assessment processes
and treatments can be adequately facilitated.
 The initiation of treatments for mood and anxiety
disorders are important as patients suffering from
anxiety disorders have a higher risk of premature death
 4. Disasters
 Natural disasters and man-made hazards can cause severe
psychological stress in victims surrounding the event.
Emergency management often includes psychiatric emergency
services designed to help victims cope with the situation. The
impact of disasters can cause people to feel shocked,
overwhelmed, immobilized, panic-stricken, or confused.
Hours, days, months and even years after a disaster,
individuals can experience tormenting memories, vivid
nightmares, develop apathy, withdrawal, memory lapses,
fatigue, loss of appetite, insomnia, depression, irritability,
panic attacks, or dysphoria.
 Dependent upon the scale of the disaster, many victims may
suffer from both chronic or acute post-traumatic stress
disorder. Patients suffering severely from this disorder often
are admitted to psychiatric hospitals to stabilize the individual
 5. Abuse, physical / sexual
 Incidents of physical abuse, sexual abuse or rape can result
in dangerous outcomes to the victim of the criminal act.
Victims may suffer from extreme anxiety, fear,
helplessness, confusion, eating or sleeping disorders,
hostility, guilt and shame. Managing the response usually
encompasses coordinating psychological, medical and legal
considerations.
 6. Psychosis

 Patients with psychotic symptoms are common in

psychiatric emergency service settings.
 An individual could also be suffering from an acute onset of
psychosis. Such conditions can be prepared for diagnosis
by obtaining a medical or psychopathological history of a
patient, performing a mental status examination,
conducting psychological testing, obtaining neuroimages,
and obtaining other neurophysiologic measurements
 7. Violent behavior

 Aggression can be the result of both internal and external

factors that create a measurable activation in the autonomic
nervous system.
 Violence is also associated with many conditions such as
acute intoxication, acute psychosis paranoid personality
disorder, antisocial personality disorder, narcissistic
personality disorder, and borderline personality disorder.
 TREATMENT
1) Medications
the rapidity of effect is an important consideration.[16]
Pharmacokinetics is the movement of drugs through the body
with time and is at least partially reliant upon the route of
administration, absorption, distribution and metabolism of the
medication
 In cases of vomiting and nausea this method of administration
is not an option. Suppositories can, in some situations, be
administered instead.[10] Medication can also be administered
through intramuscular injection, or through intravenous
injection.
 Generally, though, the timing with medications is relatively fast
and can occur within several minutes. As an example,
physicians usually expect to see a remission of symptoms thirty
minutes after haloperidol, an antipsychotic, is administered
intramuscularly.
2) Psychotherapy
 Brief psychotherapy can be used to treat acute conditions
or immediate problems as long as the patient understands
his or her issues are psychological, the patient trusts the
physician, the physician can encourage hope for change,
the patient has motivation to change, the physician is aware
of the psychopathological history of the patient, and the
patient understands that their confidentiality will be
respected.
 If the physician determines that deeper psychotherapy
sessions are required, he or she can transition the patient
out of the emergency setting and into an appropriate clinic
or center
3) Electro Compulsive Therapy (ECT)
 Electroconvulsive therapy is a controversial form of treatment
which cannot be involuntarily applied in psychiatric
emergency service settings.
 Instances wherein a patient is depressed to such a severe
degree that the patient cannot be stopped from hurting
himself or herself or when a patient refuses to swallow, eat or
drink medication, electroconvulsive therapy could be
suggested as a therapeutic alternative.
 While preliminary research suggests that electroconvulsive
therapy may be an effective treatment for depression, it
usually requires a course of six to twelve sessions of
convulsions lasting at least 20 seconds for those
antidepressant effects to occur
4) Hospital admission

 The emergency care process.

The staff will need to determine if the patient needs to be
admitted to a psychiatric inpatient facility or if they can be
safely discharged to the community after a period of
observation and/or brief treatment.
Initial emergency psychiatric evaluations usually involve
patients who are acutely agitated, paranoid, or who are
suicidal. Initial evaluations to determine admission and
interventions are designed to be as therapeutic as possible
THANK YOU