PSYCHIATRIC EMERGENCIES
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Transcript of PSYCHIATRIC EMERGENCIES
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-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.