Psychiatric Emergency

12/7/2019 Assist.Prof.Hafidh M.Farhan 1

References

Comprehensive Text book of Psychiatry

;By B.
Manual of Psychiatric Emergencies; By

Steven Hyman, and George Emergency Psychiatry; By Randy

and Brook

Sadock

and V.

Sadock

Tesar

. Hillard

Saturday, December 7, 2019

Assist.Prof.Hafidh M.Farhan

Zitek

Epidemiological data:

Psychiatric emergency rooms are used equally by men and women.

More by single than married.

About 20% of these patients are suicidal.

About 10% of these patients are violent or

agitated.

The most common diagnoses are Mood Disorders, Schizophrenia, and Alcohol Dependence.

About 40% of all patients seen in psychiatric emergency rooms require hospitalization.

Most visits occur during the night hours.

Contrary to popular belief, studies have not found that use of psychiatric emergency rooms increases during a full moon or the Christmas or Bairams, or holiday seasons.

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What are the
Psychiatric Emergency presentations?

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What are the Psychiatric Emergency presentations?

Agitation
Suicide and DSH
Loss of consciousness
Poisoning apart from suicide and DSH Substance misuse and dependency Refusal to take food
Catatonic Immobility
Severe anxiety; e.g. Panic Attack Somatoform Disorders
Factitious Disorder

Side effects of medications, particularly Antipsychotics
Any Psychiatric Disorder may present to emergency room!!!

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How to deal with an agitated patient?

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How to deal with an agitated patient?

Definitions:

Anxiety: feeling of apprehension caused by anticipation of danger, which may be internal or external.

Fear: anxiety caused by consciously recognized and realistic danger.

Tension: increased and unpleasant motor and psychological activity.

Agitation: The subjective feeling of being upset, angry, disturbed, or unable to rest.

Aggression: Destructive or punitive behavior directed toward people or objects.

Violence: Is aggressive behavior that transgresses social norms. E.g. boxing is an aggression, but street fighting is violence.

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When you receive an agitated patient in the emergency room
Try to:

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When you receive an agitated patient in the emergency room try to:

1- Ensure your own security

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When you receive an agitated patient in the emergency room try to:

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When you receive an agitated patient in the emergency room try to:

Medical conditions; delirium.
Substance/ drug misuse and dependency. Psychiatric Disorders:

Acute Psychosis Mood Disorders Anxiety Disorders Grief Reaction Personality Disorders; etc…

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Assist.Prof.Hafidh M.Farhan

When you receive an agitated patient in the emergency room try to:

3-Never confront the patient

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When you receive an agitated patient in the emergency room try to:

4- Try to calm the patient down verbally by reassuring sentences ( de- escalation)

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When you receive an agitated patient in the emergency room try to:

5- Offer help and agreement; offer food, etc………

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6- Medications:

Try oral medications at beginning; if refused then parentral.

Benzodiazepine is beneficial: Lorazepam 1-2 mgs, Midazolam 7.5-15 mgs, and Diazepam 5-10mgs; repeat as a PRN after 20- 30 minutes and for maximum of three times. If you decide to give IV Diazepam, try to give it slowly over 5 minutes to decrease the risk of respiratory depression. Keep Flumazenil amp. by hand, which should be given if the rate of respiration falls below 10/minute (amp of Flumazenil is of 0.5mgs/5ml; give 0.2mgs over 30 seconds, if consciousness not returned after 30 seconds, then give the rest of the amp over 30 seconds, if consciousness still not returned, then give another 0.5 mgs and repeat up to a maximum of 3 mgs, if after 5 minutes the patient is not awakened, then the cause of unconsciousness is not BZN).

Antipsychotics: Haloperidol 5-10mgs, Olanzapine 5-10mgs, ensure that anticholinergics or antihistamines are available before giving Antipsychotics.

Check vital signs each 5 minutes for the first hour and then half hourly until the patient become ambulant.

12/7/2019

Assist.Prof.Hafidh M.Farhan

When you receive an agitated patient in the emergency room try to:

7- Restraints:

Preferable to be done by at least 4 well trained persons.

Explain to the patient why he/she is going to restraint.

Reassure the patient continuously.

Use Leather restraints.

Try to elevate the head of the patient slightly, to prevent aspiration and to make the patient more comfortable.

The hands should be restrained in a manner that IV routes could be accessible if needed.

After restraining the patient, start treatment

When the patient become under control, remove the restraints by removing each one after 5 minutes interval, until only two remained, and then remove the remaining two restraints at once.

Thoroughly document each step you did.

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When you receive an agitated patient in the emergency room try to:

7- Restraints:

12/7/2019

Assist.Prof.Hafidh M.Farhan

YES

When you receive an agitated patient in the emergency room try to:

8- Never hesitate to call SHO on call or the specialist on call.

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When you receive an agitated patient in the emergency room try to:

1- Ensure your own security
2- Think about the possible causes for his/her agitation from the beginning: 3- Never confront the patient
4- Try to calm the patient down verbally by reassuring sentences ( de-escalation)
5- Offer help and agreement; offer food, etc………
6- Medications:

7- Restraints:
8- Never hesitate to call SHO on call or the specialist on call.

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Side effects of medications, particularly Antipsychotics

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Extra-Pyramidal Side Effects:

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Extra pyramidal Side Effects:

Are the side effects that occur with the use of dopamine antagonist agents like:

Antipsychotics (more with typical agents).

Antiemetic like metoclopramide.

Agents used for vertigo like Prochlorperazine (Stemitel).

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Extra pyramidal Side Effects:

What are the EPSs

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Extra pyramidal Side Effects:

What are the EPSs

Neuroleptic Malignant Syndrome (NMS)

Acute Dystonia Akathesia Parkinsonism

Tardive Dyskinesia

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Neuroleptic Malignant Syndrome:

Is a medical emergency, idiosyncratic reaction, may occurs even after single small sized dose, characterized by elevated temperature, impaired consciousness (semi delirious), body rigidity, sweating, and many other features including autonomic liability like increased or decreased heart rate, or blood pressure.

It is more in male and young patients, and early in the course of treatment, or it may occur in response to rapid increase in the doses of Antipsychotics.

Rate: 0.02-2.4% of those who receive anti dopamines.

Mortality: 10-20%

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Neuroleptic Malignant Syndrome:

Management:

Stop the medications

Admit the patient to intensive care unit

Rehydrate the patient with parentral fluids

Packing for the elevated temperature

Correct electrolyte disturbances (Na,K, Ca)

Check vital signs half an hourly + regular follow up

Benzodiazepine may be beneficial

Bromocriptine (dopamine agonist) may be beneficial, start with small doses and increase gradually to maximum of 60 mgs /day

Dantroline (muscle relaxant) can be used up to 10 mgs/day, but in intensive care unit. Call the SHO and the specialist psychiatrist from the beginning.

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Acute Dystonia:

Dystonia can be defined as uncontrolled spasm and posturing of a group of muscles

The important clinical types: Oculogyric crisis

Torticollis

– Dystonia occur more in young, male patients and early in treatment (more than 90% occur within the first 5 days of starting medications), it’s more with typical Antipsychotics, especially with Haloperidol, Trifluperazine.

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Acute Dystonia:

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Acute Dystonia:

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Acute Dystonia:

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Acute Dystonia:

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Acute Dystonia:

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Acute Dystonia:

Management:

Give either Anticholinergics ( Benztropine 1-4mg/day, Procyclidine 5-15mgs/day, Benzexhol 5-15mgs.day) or Antihistamine ( Diphenihydramine 25-200mgs/day)

Consider reduction in the dosage or changing the Antipsychotic.

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THANK YOU

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