Understanding Psychiatric Emergencies ABILITY TO COMPLY WITH TREATMENT
RECOMMENDATION
Psychiatric Disorders CO MORBID PSYCHIATRIC AND PHYSICAL
DISORDERS
Diagnostic and Statistical Manual of Mental Disorders QUALITY AND AVAILABILITY OF SUPPORT
(Text Revision). SYSTEMS
Commonly called the DSM-IV-TR AVAILABLE RESOURCES
CLIENT AND FAMILY PREFERENCES
Multi-axial Assessment
Axis I: Clinical disorders; other EMERGENCY ROOM PROCEDURES
conditions that may be a focus of
clinical attention.
Axis II: Personality disorders; mental
retardation.
Axis III: General medical conditions.
Axis IV: Psychosocial and environmental
problems.
Axis V: Global assessment of functioning.
Often very difficult to sort out and many patients do
not fit into the categories in the DSM.
PSYCHIATRIC EMERGENCY
DISTURBANCE IN THOUGHTS, FEELINGS, OR
ACTION FOR WHICH IMMEDIATE THERAPEUTIC
INTERVENTION IS NECESSARY
Emergency if :
Threat to:
patient’s own bodily integrity by assault, self
mutilation, drug ingestion
Somebody else’s bodily integrity
Patient’s own functional and psychological
integrity- ability to perceive reality, feel
appropriately, make judgments
Psychological and functional integrity of the
family or social unit
DEFINITIONS
AGITATION IS A STATE OF SEVERE INNER
TENSION THAT GENERALLY PRODUCES MOTOR
HYPERACTIVITY AND BEHAVIORAL
DISORGANIZATION
IMPULSIVITY TENDENCY TO ACT WITHOUT THE
ABILITY TO MATCH THE ACT TO ITS CONTEXT TO
CONSIDER THE CONSEQUENCES FOR THE SELF
OR OTHERS
AGGRESSION IS ANY BEHAVIOR THAT IS
INTENDED TO BE DESTRUCTIVE TO PERSONS,
ANIMALS OR OBJECTS
PSYCHIATRIC EMERGENCY CONSULTATION
FEMALES = MALES
SINGLE> MARRIED
20% SUICIDAL;10% VIOLENT
40% HOSPITALIZED
NIGHT HOURS
DECISION MAKING
?HOSPITALIZATION
DANGER OF HARM TO SELF OR OTHERS
LEVEL OF FUNCTIONING AND CAPACITY FOR
SELF CARE
SEVERITY OF PSYCHIATRIC SYMPTOM
CREATING AN APPROPRIATE ENVIRONMENT
PROVIDE AMPLE SPACE
AFFORD PRIVACY
MINIMIZE NOISE AND ENVIRONMENTAL
STIMULI
HAVE A WELL LIT ROOM
DEAL WITH SITUATION IN A TIMELY MANNER
ORGANIC VS FUNCTIONAL
FEATURES SUGGESTIVE TO ORGANIC CAUSES
1. ACUTE ONSET
2. FIRST EPISODE
3. GERIATRIC AGE
4. CURRENT MEDICAL ILLNESS OR INJURY
5. SIGNIFICANT SUBSTANCE ABUSE
6. NONAUDITORY DISTURBANCES OF PERCEPTION
7. NEUROLOGICAL SYMPTOMS -DECREASED
KEY SAFETY ISSUES LOC,SEIZURES, HEAD INJURY,CHANGE IN
MAKE PERSONAL AND STAFF SAFETY A HEADACHE PATTERN, CHANGE IN VISION
PRIORITY
REALIZE THAT VIOLENCE CAN OCCUR ANYTIME, CLASSIC MENTAL STATUS SIGNS – DIMINISHED
ANYWHERE ALERTNESS, DISORIENTATION, MEMORY
POSITION YOURSELF BETWEEN THE CLIENT AND IMPAIRMENT, IMPAIRMENT IN
THE EXIT CONCENTRATION, ATTENTION,
GATHER AS MUCH INFO ABOUT THE PATIENT DYSCALCULIA,CONSTRUCTIONAL APRAXIA
DIAGNOSIS SUMMARY OF EMERGENCY EVALUATION
PSYCHIATRIC INTERVIEW- HISTORY WITH MSE IS IT SAFE FOR THE PATIENT TO BE IN THE ER?
PE AND ANCILLARY TESTS IS THE PROBLEM ORGANIC OR FUNCTIONAL OR
REQUEST FOR OLD RECORDS A COMBINATION?
MULTILINGUAL STAFF IS THE PATIENT PSYCHOTIC?
RELATIVES NOT ADVISED AS TRANSLATORS IS THE PATIENT SUICIDAL OR HOMICIDAL?
TO WHAT DEGREE IS THE PATIENT CAPABLE OF
GENERAL STRATEGY SELF CARE?
PSYCHIATRIC EMERGENCY CONSULTATION
FEMALES = MALES
SINGLE> MARRIED
20% SUICIDAL;10% VIOLENT
40% HOSPITALIZED
NIGHT HOURS
AGITATED PATIENT
Initial management should focus to calm
patient through emphatic yet firm verbal means
and establish collaborative relationship
Inform patient that he may say or feel anything
but are not free to act in violent or threatening
manner
Rapid neureptilization
ACUTE PSYCHOTIC STATES
1. IMPAIRMENT OF IMPULSE CONTROL
CAPACITY TO RESTRAIN RAPIDLY
?ORGANIC OR NOT(ACUTE ALCOHOL
INTOXICATION)
NE/PE
IMMEDIATE TRANQUILIZATION- EXCEPTION
SEDATING DRUG IM OR IV
2. IMPAIRMENT IN PERCEPTION
?ORGANICITY
DRUG INTOXICATION
DRUG WITHDRAWAL
DEMENTIA
3. IMPAIRMENT IN THINKING
SCHIZOPHRENIC DISINTEGRATION:
A. AGITATED, DISORGANIZED THINKING
B.WITHDRAWN/ISOLATED/MUTE
C.INCREASED SYMPTOMS
ANXIETY, DEPRESSION, MANIA
INTERVIEW SITUATIONS (PSYCHOSIS)
WITHDRAWAL FROM OBJECTIVE REALITY
PARANOIA USE OF RESTRAINTS
COMMAND HALLUCINATIONS
LIMIT POTENTIAL FOR AGITATION OR
REGRESSION
ACUTE PSYCHOTIC STATE
MANIA
QUALITY OF MANIC EPISODE
FIRST RECOGNIZED MANIC EPISODE
PATIENT’S PHYSICAL CONDITION
IS PATIENT ON LITHIUM MAINTENANCE
?CONTENT OF THOUGHT
DRUGS
Lor azepam 2 to 6 mg po/im
Haloperidol PO/IM 2 – 5 mg every 4 to 6 hrs.
Risperidone PO 1 mg bid initially, increase as
tolerated up to 3mg bid
Olanzapine PO/IM 5 to 10 mg initially increase
up to 20 mg daily
PRINCIPLES
DEAL WITH THE HEALTHY EGO
ESTABLISH CONTROLS
HALOPERIDOL IM 2 TO 10 MG Q 45MIN.
RISPERIDONE QUICKLET
IV DIAZEPAM
INTERVIEW SITUATIONS (VIOLENT PATIENTS)
PREDICTORS OF VIOLENCE
1. EXCESSIVE ALCOHOL INTAKE
2. HISTORY OF VIOLENT ACTS
3. HISTORY OF CHILDHOOD ABUSE
ASSESSING & PREDICTING VIOLENT BEHAVIOR Psychiatric Disorders
Not so important to classify a patient’s
psychiatric condition as it is to recognize
patterns that may put the patient or others at
risk.
Important to exclude medical causes of
behavioral problems before concluding they are
psychiatric.
Substance abuse complicates many psychiatric
conditions, and may be the primary cause of
others.
Remember, sometimes the only
difference between us and them is
the fact that we have the keys!
---------------------VVV--------------------
