Transcript 14- psychiatric emer..

PSYCHIATRIC
EMERGENCIES
Dr. Rabie Hawari
Consultant Psychiatrist
Clinical Assistant Professor
SUICIDE
A willful self-inflicted lifethreatening act which has
resulted in DEATH.
ATTEMPTED SUICIDE
OR DELIBERATE SELF-HARM
OR PARASUICIDE
* An act of self-damage carried out
with destructive intent.
* An attempt without the will to
finish one’s life.
SUICIDE RISK FACTORS
• Previous Hx. Of Affective Disorder =
Depression.
• Hx. Of Alcoholism & Drug Abuse.
• Sever physical illness in the elderly = Ca.
• Recent bereavement, separation, loss.
• Family Hx. Of Affective Illness.
• Previous Suicidal Attempts.
• Personality problems i.e. Cyclothymic,
Antisocial.
• Poor social support, living alone,
unemployed, single.
• Other symptoms: Agitation, Insomnia, Guilt,
Male, Older age, Divorced, Suicidal threats.
METHODS USED
examples;
Self-poisoning:- coal gas poisoning.
Drugs- tranquilizer,
Salicylates,
Antidepressant.
Violent means:- hanging, firearm, cutting,
etc.
MANAGEMENT
•
•
•
•
•
•
•
Active treatment of the physical
condition.
Detect high risk group.
Close observation 1=1.
Treatment of any Psy. Illness.
Social & Psychological support.
Admission to Psych. Unite if the
immediate crisis passed & the Pt. suffers
from Psych. Illness & of high risk group.
If the situation is not one of OD. Pt. may
need sedation e.g. Nitrazepam 10-15mg.
CPZ. 100-200mg.
DELIBERATE SELFHARM
An attempt without the will to finish
one’s life.
Causes:- personality Diso. e.g. Psychopath or
Hysterics
- alcoholism.
- reactive ( neurotic ) depression.
- situational crisis.
Correlating Factors:- not well planned act.
- female, young, unemployed,
single.
- previous attempts,
psychosocial stresses.
- broken home background
Management of DSH:- assessment of physical
seriousness
- admission.
- assessment for Suicide Risk
Factor.
- treatment of any Psychiatric
Illness.
- psychotherapy.
SIDE-EFFECT OF
PSYCHOTROPIC DRUGS
A. Neuroleptic Malignant Synd.
(NMS):Is an acute or subacute Hyperthermic
reaction to neuroleptic therapy with a
mortality of 20%.
Features:- Hi. Fever … Extrapyramidal
rigidity … Altered consciousness …
Raised Creatine Phosphokinase (cpk)=
15000iu/l.
Management of NMS:Stop all neuroleptic drugs. Vigorous cooling is needed.
Oxygen, i.v. hydration, prevention of renal
failure, bicarbonate for acidosis.
Dantrolene sodium 200mg (slow),1.25-10/kg.
i.v.(fast) for 12-48hr. after control of fever. or
Bromocriptine p.o. or i.v.(^ 60 mg/day)
rigidity.
Cont. S/E. of Psych. Drugs;
B. Acute Dystonia:-
Involuntary contraction
of skeletal muscles in head & neck
 Oculogyric Crisis
Management:- I.M. Procyclidine (kemedrine)
5-15mg.
- Diazepam 10mg i.v.
Cont. S/E. of Psych. Drugs;
C. Akathisia:- Minor restlessness &
tension. pt. unable to keep from
fidgeting, subjective feel of
restlessness.
Management:- Anti-parkinsonian
drug.
S/E. of Psych. Druges
D. Pseudoparkinsonism:This mimic idiopathic
Parkinsonism:- stiffening of the limbs,
- lack of facial expression,
- tremor of hands & head at rest,
- sialorrhoea & seborrhoea.
Management of Ps-Parkinsonism:Stop the drug temporarily or sharply
reduce the dose.
Use Anti-Parkinsonian Drugs:= Benzhexol (Artane) 2- 4mg.t.i.d.
= Procyclidine ( Kemedrine) 5-15tid.
= Orphenadrine( Disipal ) 50 -100mg
tid.
MANAGEMENT OF VIOLENT
PATIENT
Usually the majority of
Psychiatric patients are not
Hostile, Dangerous or
aggressive, BUT occasionally
Psychiatric Illness presented in
Aggressive Behavior
Examples of Violent Pts.:1. Psychopathic Personality Disorder.
2. Hypomania or mania >>> may be
angry & hostile if they are obstructed
3. Schizophrenia >> due to Delusional
beliefs or in response to auditory
Hallucination.
Catatonic type >> outbursts of over
activity &/or aggressive behavior.
Cont. examples of violent Pts.
4. Alcohol & Drugs:Alcohol >> reduce self-control>>
aggression
C.N.S. stimulants ( amphetamine ) >>
over activity & over stimulation >>>
Aggression.
Heroin addicts during Withdrawal phase.
Cont. Examples of Violent Pts.:5. Acute Confusional State >>
clouding of consciousness >>>
diminished comprehension, anxiety,
perplexity, delusion of persecution
>>>> Aggression.
6. Epilepsy:- in the post-epileptic
confusional state.
Cont. Examples of Violent Pts.
7. Dementia:- cerebral damage >>>>
decreased control >> aggression
Catastrophic Reaction:- when facing
difficult tasks they become
restless, disturbed, angry,
aggressive, throw things
&
attack people mostly at night.
MANAGEMENT OF
VIOLENT PT.
- Doctors, Nurses, relatives should
treat such pt. with understanding &
gentleness as possible.
- Adequate security.
- Raise of alarm.
- Availability of more staff.
- clear prevention policy to all.
- Remain calm, non-critical.
Cont. Manage. Of Violent pt.
- Use minimum force with adequate
numbers of staff.
- Talk pt. down.
- Physical restrain.
- Medication:* typical :- Major Tranquilizer
. Chlorpromazine 50-100mg im
. Droperidol 10-20mg im or iv.
. Clopixol Aquaphase 50-100mg im
* atypical:- risperidone 4mg Or
zyprexia 10mg im.
Cont. manage. Of violent pt.
Medication cont.:* Benzodizepine:- Diazepam 5-10mg
iv. In epilepsy, withdrawal of
alcohol or barbiturates.
( may disinhibit violence.)
DELIRIUM TREMENS
D.T. :- arises 2-4 days after sudden
withdrawal or stopping of alcohol
features:- hallucinate, delusion,
confused, inattentive, agitated, restless,
insomnia, tearful, autonomic overactivity,
coma, death.
management:- Benzodiazepine p.o or iv. to
reduce WD symptoms in large doses &
taper off in a wk. + large doses of vit. B.
and correct fluid & electrolyte.
ACUTE CONFUSIONAL
STATE.
Characterized by :* clouding of consciousness,
* disorientation,
* visional hallucination,
* perplexity, disturbed behavior.
Management:- admission,
- treat underlying cause ( infection)
- explain to pt. investigations, treatment,
in clear voice & well lit room, reduce staff
- chlorpromazine or haloperidol for control.
ACUTE ATTACKS OF
ANIETY OR PANIC
Features:1. experiences of intense terror,
2. sweating & drying of mouth,
3. feeling of distress in chest &
pericardial pains,
4. transmitted to members of family,
5. often at w/ends or middle of the night.
Management:- reassurance,
- Benzodiazepine. ( diazepam 5-10mg po/iv)
OTHERS:STUPOR:-
cause Akinesia, Immobility, Muteness with
preserved consciousness. It is life
threatening b/c of dehydration.
causes :- functional depression, catatonia,
hysterical, mania.
- organic 20%, Brain Stem Lesions,
lesions around 3rd.Ventrical.
management:- Abreaction ( Na. amytal or Diazepam)
- ECT. - And treat the underlying.
OTHERS:BRIEF REACTIVE PSYCHOSIS:emotional turmoil, extreme liability,
impaired reality testing after obvious
psychosocial stress.
Management:- admit, antipsychotic,
resolves spontaneously.
OTHERS:-
HYPERVENTILATION:anxiety, terror, clouded conscious,
giddiness, faintness, blurring vision.
Management:- breathe into bag shift
alkalosis, education, antianxiety
agent.