Transcript PSYCHIATRIC EMERGENCIES - Accra Psychiatric Hospital

PSYCHIATRIC
EMERGENCIES
Prof J.B.ASARE
CONSULTANT PSYCHIATRIST

Emergency psychiatry identifies and
treats emergencies related to mental
diseases, social problems resulting in
sudden behavioral change and mental
disturbances associated with some types
of physical illness
EMERGENCIES IN PSYCHIATRY








Attempted suicide/parasuicide
Severe Depression with suicidal ideas
Substance abuse/intoxication and
withdrawal states
Delirium tremens
Violent Behavior
Hazardous drug reaction
Neuroleptic Malignant Syndrome
Status Epilepticus
Types of Emergencies

-


Mode : cutting the wrists,
overdose of drugs,
using toxic substances like rat killers,
herbicides corrosive substances.
Gender- more girls than boys in the
teenage period but more men than women
in those above the age of 50years
Risk of suicide 1% and higher in men than
women and increases with age.It is about 7
times higher in those above 55years at the
time of self harm
Attempted suicide

-
-
Causes
Call for help
Attention seeking behaviour?
For secondary gain
Psychotic behaviour
Depression/Emotional problems
Stress
Crisis situation
Attempted Suicide

Risk factors:
Family conflict
Abuse and neglect
Life events such as loss and trauma
Relationship difficulties
Feeling rejected
Temperament
Personality
Depression
Eating disorders
Young people who use drugs and alcohol
Attempted suicide

Risk factors for suicide:
Young men
Mental health difficulties
Personality difficulties
Stressful events
Young people who regularly self harm
Drug and alcohol use
Attempted suicide
Within a protected environment,
psychiatric emergency services exist to
provide brief stay of two or three days to
gain a diagnostic clarity and provide first
aid
 Treat those patients whose symptoms can
be improved within that brief period of
time.
 Find appropriate alternatives to
psychiatric hospitalization for the patient.

Management





Assessment –psychiatric history; Physical
assessment and evaluation of health
status
Assessment of danger and provision of
security
Social and psychological evaluation(if
necessary)
Arranging for social support
Counseling and treatment of underlying
psychopathology
Management





Pt has clinical symptoms of severe
depression (e.g. Wt loss, poor appetite,
insomnia, social withdrawal, negative
thoughts etc)
Suicidal ideas are paramount
Has limited social support
Not being treated for depression
There may be a long standing social
problem with a state of helplessness
Severe Depression







Refer or admit if specialist facility is available
Arrange for social enquiry and support
Detail somebody to supervise
Remove offensive materials/equipment that
can be used for suicide e.g. drugs, chemicals
, sponge, belt, rope, tie etc
Sedate and use antidepressants.
Counselling
Consider ECT
Intervention
Substances such as Heroin, Pethidine
and codeine produce intoxication when
taken in heavy doses (”bad trip’)
 This will manifest as delirium with
accompanying behavioral problems.
 Some cannabis and cocaine abusers can
present with acute psychotic behaviours
manifesting as violent and aggressive
behaviours.

Substance Abuse intoxication and
withdrawal
Assessment – Psychiatric and physical
 Admit
 Apply intra muscular injection of
nueroleptics or intravenous sedation
using Diazepam
 Organize social, psychological and
psychiatric interventions through referral

Management
Acute Alcohol withdrawal in alcoholics who
had abstained from alcohol from 2472hours or those who did not have
enough alcohol to drink during a bout.
 They manifest with Coarse tremors,
sweating, restlessness, visual
hallucinations and some level of
aggressiveness and confusion

Delirium Tremens
A medical emergency
Check vitals
Provide infusions
Iv Diazepam 10 -20mg
Iv Parenterovite 1 & 2 or thiamine 50-100mg
- May require inj im 50mg of
chlorpromazine to settle if liver is ok
- Anticonvulsants may be necessary if seizures
are present
- Observe

-
Management

-
Continue with sliding doses of Diazepam and
tab thiamine
e.g. 1st day diazepam 10mg qds
2nd day ‘
‘’
10mg tds.
3rd day ‘’
‘’
10mg bd
4th day ‘’
‘’
10mg daily
5th day ‘’
‘’
5mg daily
- continue with vitamins and refer to
AA(Alcoholic Anonymous)
Counseling and Rehabilitation
Management



Aggression can be the result of both internal
and external factors that create a measurable
activation in the autonomic nervous system .
This activation can become evident through
symptoms such as the clenching of fists or
jaw, pacing, slamming doors, hitting palms of
hands with fists, or being easily startled
Violence is also associated with many
conditions such as, acute psychosis, acute
alcohol intoxication ,Paranoid personality
disorder, antisocial personality disorder etc
Violent Behaviors
Risk factors may include :- Previous history of arrests
- presence of hallucinations
- delusions,
- Handicapped in reasoning,
- Use of psychoactive substances etc
Violent Behaviour





Assessment of the person and local
security
Mobilize more hands for support
Assess eye to eye contact and readiness
to respond to suggestions
Attempt Physical examination and quick
MSE
Consider chemical restraint if cooperation
is not being assured and the person is a
risk to him/herself or others
Management of aggressive patient





iv Diazepam 20mg for an adult in bolus
dosage
Precautions should be taken if the patient
has respiratory problems.
Inject im. chlorpromazine 100-200mg st.
Ensure that the BP is not below 100 mm
Hg systolic
Admit and observe
Rapid Tranquillization
Laboratory investigation
 Exclude space occupying lesion.
 Give medication to control aggression,
mood and psychotic symptoms if available
 Psychotropic medication, mood stabilizers
such as Sodium valporate, Carbamazepine
can be used.

Management of violent person
Clinical implications
When a person suffering from Schizophrenia or
another psychotic illness
Is violent, delusions are likely to be a major
factor in causing the offence
Alcohol and illicit substance misuse has
probably become more prevalent among
people with serious mental disorder
manifesting with violent behaviour and
targeted attention should be given to them

Violent Behaviour






Dangerous reactions from psychiatric
medications, especially antipsychotics, are
considered psychiatric emergencies. E.g.
Ocurogyric crisis,
Dystonic reaction
Tremors and restlessness.
Protruding of the tongue
Excessive salivation
Hazardous Drug Reactions


-
Causes
Blockade of the dopamine receptor D1
implicated leading to abnormal functions of
the basal ganglia.
The use of antipsychotic drugs like
haloperidol and chlorpromazine common
People using dopaminergic drugs such as
levodopa for Parkinson’s disease
Even some drugs without known anti –
dopaminergic activity such as
lithium,desipramine,dothiepin,phenelzine etc
have been associated with NMS
Neuroleptic Malignant syndrome







Neuroleptic malignant syndrome is a potentially lethal
complication of first or second generation
antipsychotics.
If untreated, neuroleptic malignant syndrome can
result in fever, muscle rigidity, confusion, unstable
vital signs, or even death.
Stop the Neuroleptic
Give infusions
Treat hyperthermia aggressively such as using cool
blankets and ice packs to the axillae and groin
Supportive care in intensive unit may be desirable
Benzodiazepines may be used to reduce agitation
Management of NMS
Symptoms
- Muscle cramps, tremors and fever

-
Symptoms of autonomic nervous system
instability such as unstable blood pressure
-
Alterations in mental state such as
agitation, delirium and coma
Neuroleptic Malignant Syndrome
Reassure client
 Administer Anti cholinergic medication
e.g. Iv Benztropine 2mg
 If not available, tab. benztropine 2mg bd
or tab. Benzhexol
 In very severe cases, injection Diazepam
between 5-10mg could be given and the
patient detained for a few hours.

Management of drug reactions
Frequent continuous seizures which can
lead to brain irreversible damage.
 Children and the aged are vulnerable
 It becomes a medical/Psychiatric
emergency because sufferers can lose
their lives in the process of frequent
seizures through asphyxia

Status Epilepticus
In iv Diazepam 10 -20mg can be given
cautiously
 Or Iv Phenytoin 100mg
 Then continue with anticonvulsants
 Counseling

Management of status epilepticus

Crisis Intervention can be defined as
emergency psychological care aimed at
assisting individuals in a crisis situation to
restore equilibrium to their biopsychosocial functioning and to minimize
the potential for psychological trauma
Crisis Intervention

Crisis can be defined as one’s perception
or experiencing of an event or situation as
an intolerable difficulty that exceeds the
person’s current resources and coping
mechanisms
Crisis Intervention


Personal trauma and Societal or mass trauma
Personal Trauma is defined as an individual’s
experience of a situation or event in which
he/she perceives to have exhausted his/her
coping skill, self-esteem, social support and
power. These can be situations where a
person is making suicidal threats,
experiencing threat, witnessing homicide or
suicide, or experiencing personal loss.
Types of crisis

Societal or mass trauma can occur in a
number of settings and typically affect a
large group or society. These are
instances such as school shootings,
terrorist attacks, and natural disaster.
Types of crisis
On the cognitive level they may blame
themselves or others for the trauma.
 Oftentimes the person appears
disoriented, becomes hypersensitive or
confused,
 Has poor concentration, uncertainty,
 Physical responses to trauma include:
increased heart rate, tremors, dizziness,
weakness, chills, headaches, vomiting,
shock, fainting, sweating, and fatigue

Typical Responses to crisis

Emotional responses consist of apathy,
depression, irritability, anxiety, panic
helplessness, hopelessness, anger, fear,
guilt, and denial. When assessing
behavior some typical responses to crisis
are difficulty in eating and/or sleeping,
conflicts with others, withdrawal from
social situations, and lack of interest in
social activities.
Responses to crisis






Intervene as quickly as possible.
Assess the needs of the person or survivors if it
is mass trauma
Resource mobilization should be immediately
embarked upon in order to provide victims with
the tools they need to return to some sort of
order and normalcy,
In addition they are to be helped to function
independently.
The next step is to facilitate understanding of
the event by processing the situation or trauma
Referrals to be made after assessment to
specialized areas
Intervention