PSYCHIATRIC EMERGENCIES

OUTLINE
1. INTRODUCTION & EVALUATION
2. EMERGENCIES IN ADULTS
3. SUICIDE AND SELF-HARM
4. EMERGENCIES IN CHILDREN
INTRODUCTION
Psychiatric Emergencies
• A psychiatric emergency is any disturbance in thoughts, feelings or
actions for which immediate therapeutic intervention is necessary
(Kaplan & Sadocks)

• Increasing in number – violence, alcoholism, substance, etc

Epidemiology
• Equal men:women
• 20% suicidal, 10% violent
• Most common case are mood disorders, schizophrenia, alcohol
dependence.
• 40% require hospitalization
• More visit during night hours
Treatment Settings
Specializes psychiatric services are highly favoured in emergency room

SAFETY & SECURITY!

Adequate number of staff members

Clear communications, staff must understand situation

Children are better treated under paediatrics care except there is a risk of
behavioural problems or leaving the hospital against advice.
 Access to emergency room &
diagnostic services
Agitated patients must be
separated
Treatment Restrain rooms close to nursing
Settings station for close observation
Evaluation
 1. Self-protection
• Know as much as possible about the patients before
meeting them.
• Leave physical restraint procedures to those who
General are trained.
• Be alert to risks of impending violence.
Strategy in • Attend to the safety of the physical surroundings
(e.g., door access, room objects).
Evaluating the • Have others present during the assessment if
Patient needed.
• Have others in the vicinity.
• Attend to developing an alliance with the patient
(e.g., do not confront or threaten paranoid patients)
 2. Prevent harm
A. Prevent self-injury and suicide. Use whatever methods are
necessary to prevent patients from hurting themselves
during the evaluation.
B. Prevent violence toward others. Evaluate risk of violence:
General • Inform the patient that violence is not acceptable.
• Approach the patient in a nonthreatening manner.
Strategy in • Reassure, calm, or assist the patient's reality testing.
• Offer medication.
Evaluating the • Inform the patient that restraint or seclusion will be
used if necessary.
Patient • Have teams ready to restrain the patient.
• When patients are restrained, always closely observe
them, and frequently check their vital signs. Isolate
restrained patients from surrounding agitating stimuli .
General
3. Rule out organic mental disorders.
Strategy in
4. Rule out impending psychosis.
Evaluating the
Patient
Medical or Psychiatric?
• Medical conditions-such as diabetes mellitus, thyroid disease, acute
intoxications, withdrawal states, AIDS, and head traumas---can
present with prominent mental status changes that mimic common
psychiatric illnesses
Features that Point to a Medical Cause of a
Mental Disorder
• Acute onset (within hours or minutes, with prevailing symptoms) First episode
• Geriatric age
• Current medical illness or injury
• Significant substance abuse
• Nonauditory disturbances of perception
• Neurological symptoms-loss of consciousness, seizures, head injury, change in headache
pattern, change in vision
• Classic mental status signs-diminished alertness, disorientation, memory impairment,
impairment in concentration and attention, dyscalculia, concreteness
• Other mental status signs-speech, movement, or gait disorders
• Constructional apraxia-difficulties in drawing clock, cube, intersecting pentagons, Bender
gestalt design
 • Psychosis
• Important parameters:
• Degree of withdrawal from reality
• Level of affect
SPECIFIC • Intellectual function
INTERVIEW • Degree of regression
• Straightforward, easy to understand
SITUATIONS • Not all patients want our help
• Limit interview if there is potential for
agitation or regression
 • Depression and potentially suicidal patients
• Suicidal risks:
• Previous attempt or fantasized suicide
• Anxiety, depression, exhaustion
• Availability of means of suicide
SPECIFIC • Concern for effect of suicide on family
members
INTERVIEW • Verbalized suicidal ideation
• Preparation of a will, resignation after
SITUATIONS agitated depression
• Proximal life crisis, such as mourning
or impending surgery
• Family history of suicide
• Pervasive pessimism or hopelessness
 • DDX may include psychoactive
substance induces, organic mental
disorders, medical cause, etc.
• Signs of impending violence
• Very recent acts of violence, including
property violence
• Verbal or physical threats (menacing)
VIOLENT • Carrying weapons or other objects that
may be used as weapons (e.g., forks,
ashtrays)
PATIENTS • Progressive psychomotor agitation
• Alcohol or drug intoxication
• Paranoid features in a psychotic patient
• Command violent auditory hallucination
• Catatonic excitement
• Mania or agitated depression
• Personality disorder
 • Assess the risk of violence
• Consider violent ideation, wish,
intention, plan, availability of
means, implementation of plan,
wish for help.
• b. Consider demographics-sex
(male), age (1 5-24), socioeconomic
VIOLENT status (low), social supports (few).
• c. Consider past history: violence,
PATIENTS nonviolent antisocial acts, impulse
dyscontrol (e.g., gambling,
substance abuse, suicide or self-
injury, psychosis).
• d. Consider overt stressors (e.g.,
marital conflict, real or symbolic
loss).
 • Rape is the forceful coercion of an unwilling
victim to engage in a sexual act, usually
sexual intercourse
• Reactions- shame, humiliation, anxiety,
confusion, outrage
• Clinicians should be-reassuring, supportive,
non-judgemental
• Inform patients about the availability of
RAPE VICTIMS medical and legal services, rape crisis
centres
• If possible, female attending doctor evaluate
patients.
• Patients consent – to collect evidence such
as semen, pubic hair, take photographs of
evidence.