psychiatric emergencies dr. rabie hawari consultant psychiatrist clinical assistant professor

PSYCHIATRIC EMERGENCIES

Dr. Rabie Hawari Consultant Psychiatrist

Clinical Assistant Professor

SUICIDE

A willful self-inflicted life-threatening act which has resulted in DEATH.

ATTEMPTED SUICIDE

OR DELIBERATE SELF-HARMOR 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 SELF-HARM

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 DRUGSA. 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>> aggressionC.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 PANICFeatures-:

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.