Psychiatric Emergencies

Dr. Adel Ahmed Alzayed

Kuwait university – Medical college

Department of Psychiatry

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 To be able to describe the common types and causes of
psychiatric emergencies.
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 To be able to describe acute management of common

psychiatric emergencies.

Objectives
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 History
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 Collateral history
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◦ Is it a chronic problem? Crisis ? Why now? What

are the expectations?

General assessment
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Physical examination
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◦ Uncooperative agitated inappropriate patients tend

to aggravate staff and lead to inadequate
medical care and not be examined properly.
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General assessment
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Mental state examination
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Investigation - Laboratory – screens- Imaging

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General assessment
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 Aims
◦ Engagement
◦ Assess future risk
◦ Identify risk factors for harm (especially
modifiable maintaining factors )
◦ Create management plan
◦ Understand the patients wish to die
◦ Diagnose psychiatric disorder if present

Assessment of the suicidal

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
 S ­ Sex
 A ­ Age
 D­ Depression
 P ­ Psychiatric care
 E ­ Excessive drug use
 R ­ Rational thinking absent
 S ­ Single
 O ­ Organized attempt
 N ­ No supports (isolated)
 S ­ States future intent

Risk factors for suicide

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Not just psychiatric disorders (although commonest

cause).
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Numerous “non-psychiatric” causes

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Needs full medical/psychiatric work up

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High dose benzodiazepines/ECT

Catatonia/Mute
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 Agitation is excessive motor or verbal activity.
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 Common examples include:

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◦ hyperactivity
◦ verbal abuse
◦ threatening gestures and language
◦ physical destructiveness
◦ vocal outbursts
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Agitation
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 Commonest psychiatric disorders that present with

violence:
◦ psychotic disorders (schizophrenia, mania, paranoid
states,+/-hallucinations),
◦ drug abuse
◦ alcohol abuse
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 Of violent people with schizophrenia 71% are

substance abusers (12 times risk violence).
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 Organic brain syndromes (7-28%)

Violent Patient
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Ensure safety of patient and staff.
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To determine if ideation or behavior stems from specific

psychiatric illness.
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Warn third parties of a serious threat of harm is present.

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To draw an effective and appropriate treatment plan.

Violent Patient
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Remove potential weapons e.g. keys, chairs.

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Get other patients to safe place.

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Put patient in quiet setting, reduce stimulation.

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Attitude - nonjudgmental, calm, helpful, slow,

predictable. Speak softly, never turn back
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Offer reassurance and support allow ventilation

Non pharmacological intervention

 Preferred
Verbal intervention
Voluntary medication
Show of force
Emergency medication
Offer food beverage or other assistance
Alternate

Restraints – physical , locked seclusion

Intervention for imminent violence

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 Classical Neuroleptics:
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◦ Haloperidol(5-10mgs)
◦
◦
 Novel
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◦ Risperidone
◦ Olanzapine
◦ Quetiapine
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 Benzodiazapines
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◦ Lorazepam(1-4 mgs)

Oral options
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Haloperidol (5-10 mgs)
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Zuclopenthixol Accuphase
◦ Reduces injection frequency but it has a delayed onset
of action 3-4 hours, effects last 2-3 days, including
sedation, EPS
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Lorazepam 2-4 mgs

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Olanzapine

I.M. options
Flow chart for rapid tranquillisation of acutely disturbed patient

Atakan, Z. et al. BMJ 1997;314:1740

 Disturbance in
◦ consciousness
◦ alertness,
◦ awareness,
◦ sustain or shift attention.


 Cognition - poor memory due to inattention and

registration, thought disorganized, perceptual
distortions, mood liability, fail recognize
people
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 Fluctuations, temporal course worse night , onset
sudden
Delirium