PSYCHIATRIC EMERGENCIES

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					PSYCHIATRIC
EMERGENCIES

      Dr. Rabie Hawari
   Consultant Psychiatrist
SUICIDE

 A willful self-inflicted life-
threatening 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 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 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.

				
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posted:3/11/2012
language:English
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