College of Medicine; Department of Psychiatry; 5th Year
Dr.Twana A Rahim
2009/2010
Psychiatric Emergencies:
Epidemiological data:
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Psychiatric emergency rooms are used equally by men and women.
More by single than married.
About 20% of these patients are suicidal.
About 10% of these patients are violent or agitated.
The most common diagnoses are Mood Disorders, Schizophrenia, and Alcohol Dependence.
About 40% of all patients seen in psychiatric emergency rooms require hospitalization.
Most visits occur during the night hours.
Contrary to popular belief, studies have not found that use of psychiatric emergency rooms increases during a
full moon or the Christmas or Bairams, or holiday seasons.
What are the Psychiatric Emergency presentations?
1- Agitation
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Suicide and DSH. (review the relevant lecture)
Loss of consciousness. (review the lectures of Neurology)
Substance misuse and dependency. (review the relevant lecture)
Refusal to take food. (review the relevant lectures)
Catatonic Immobility. (review the relevant lecture)
Severe anxiety; e.g. Panic Attack. (review the relevant lecture)
Somatoform Disorders. (review the relevant lecture)
Factitious Disorder. (review the relevant lecture)
10- Side effects of medications, particularly Antipsychotics
11- Any Psychiatric Disorder may present to emergency room!!!
How to deal with an agitated patient?
Definitions:
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Anxiety: feeling of apprehension caused by anticipation of danger, which may be internal or external.
Fear: anxiety caused by consciously recognized and realistic danger.
Tension: increased and unpleasant motor and psychological activity.
Agitation: The subjective feeling of being upset, angry, disturbed, or unable to rest.
Aggression: Destructive or punitive behavior directed toward people or objects.
Violence: Is aggressive behavior that transgresses social norms. E.g. boxing is an aggression, but street
fighting is violence.
When you receive an agitated patient in the emergency room, try to:
1- Ensure your own security.
2- Think about the possible causes for his/her agitation from the beginning:
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Psychiatric Emergencies
College of Medicine; Department of Psychiatry; 5th Year
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Dr.Twana A Rahim
2009/2010
Medical conditions; delirium.
Substance/ drug misuse and dependency.
Psychiatric Disorders:
Acute Psychosis
Mood Disorders
Anxiety Disorders
Grief Reaction
Personality Disorders; etc…
Never confront the patient.
Try to calm the patient down verbally by reassuring sentences (de-escalation).
Offer help and agreement; offer food, etc…
Medications:
Try oral medications at beginning; if refused then parentral.
Benzodiazepine is beneficial: Lorazepam 1-2 mgs, Midazolam 7.5-15 mgs, and Diazepam 5-10mgs; repeat as a
PRN after 20- 30 minutes and for maximum of three times. If you decide to give IV Diazepam, try to give it
slowly over 5 minutes to decrease the risk of respiratory depression. Keep Flumazenil amp. by hand, which
should be given if the rate of respiration falls below 10/minute (amp of Flumazenil is of 0.5mgs/5ml; give
0.2mgs over 30 seconds, if consciousness not returned after 30 seconds, then give the rest of the amp over 30
seconds, if consciousness still not returned, then give another 0.5 mgs and repeat up to a maximum of 3 mgs,
if after 5 minutes the patient is not awakened, then the cause of unconsciousness is not BZN).
Antipsychotics: Haloperidol 5-10mgs, Olanzapine 5-10mgs, ensure that anticholinergics or antihistamines are
available before giving Antipsychotics.
Check vital signs each 5 minutes for the first hour and then half hourly until the patient become ambulant.
Restraints:
Preferable to be done by at least 4 well trained persons.
Explain to the patient why he/she is going to restraint.
Reassure the patient continuously.
Use Leather restraints.
Try to elevate the head of the patient slightly, to prevent aspiration and to make the patient more
comfortable.
The hands should be restrained in a manner that IV routes could be accessible if needed.
After restraining the patient, start treatment
When the patient become under control, remove the restraints by removing each one after 5 minutes interval,
until only two remained, and then remove the remaining two restraints at once.
Thoroughly document each step you did.
Never hesitate to call SHO on call or the specialist on call.
Side effects of medications, particularly Antipsychotics:
Extra pyramidal Side Effects:
Are the side effects that occur with the use of dopamine antagonist agents like:
1- Antipsychotics (more with typical agents).
2- Antiemetic like metoclopramide.
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Psychiatric Emergencies
College of Medicine; Department of Psychiatry; 5th Year
Dr.Twana A Rahim
2009/2010
3- Agents used for vertigo like Prochlorperazine (Stemitel).
What are the EPSs?
1- Neuroleptic Malignant Syndrome (NMS)
2- Acute Dystonia
3- Akathesia
4- Parkinsonism
5- Tardive Dyskinesia
Neuroleptic Malignant Syndrome:
Is a medical emergency, idiosyncratic reaction, may occurs even after single small sized dose, characterized by
elevated temperature, impaired consciousness (semi delirious), body rigidity, profound sweating, and many
other features including autonomic liability like increased or decreased heart rate, or blood pressure.
On laboratory examination, there might be an elevated muscle enzymes (creatine phosphokinase) and
leukocytosis.
It is more in male and young patients, and early in the course of treatment, or it may occur in response to
rapid increase in the doses of Antipsychotics.
Rate: 0.02-2.4% of those who receive anti dopamines.
Mortality: 10-20%.
Possible Causes of Death in NMS:
1- Excessive sweating resulted in hypovolumic shock.
2- Excessive sweating resulted in hypovolumic acute renal failure.
3- Myoglubinurea (due to muscle damage resulted from extreme rigidity) leading to acute renal failure.
4- Electrolyte disturbances.
5- Aspiration as a result of extreme muscle contractions and difficulty in swallowing.
6- Respiratory failure.
Differential Diagnosis:
1- Meningitis.
2- Encephalitis.
3- Catatonic Schizophrenia.
Management:
1- Stop the medications.
2- Admit the patient to intensive care unit.
3- Rehydrate the patient with parentral fluids.
4- Packing for the elevated temperature.
5- Correct electrolyte disturbances (Na, K, Ca).
6- Check vital signs half an hourly + regular follow up.
7- Benzodiazepine may be beneficial.
8- Bromocriptine (dopamine agonist) may be beneficial, start with small doses and increase gradually to
maximum of 60 mgs /day.
9- Dantroline (muscle relaxant) can be used up to 10 mgs/day, but in intensive care unit.
10- Call the SHO and the specialist psychiatrist from the beginning.
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Psychiatric Emergencies
College of Medicine; Department of Psychiatry; 5th Year
Dr.Twana A Rahim
2009/2010
Acute Dystonia:
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Dystonia can be defined as uncontrolled spasm and posturing of a group of muscles
The important clinical types:
Oculogyric crisis
Blepharospasm
Torticollis
Opisthotonus
Pleurothotonus
Dystonia occurs more in young, male patients and early in treatment (more than 90% occur within the first 5
days of starting medications), it’s more with typical Antipsychotics, especially with Haloperidol, and
Trifluperazine.
Management:
Give either Anticholinergics ( Benztropine 1-4mg/day, Procyclidine 5-15mgs/day, Benzexhol 5-15mgs.day) or
Antihistamine ( Diphenihydramine 25-200mgs/day)
Consider reduction in the dosage or changing the Antipsychotic.
END
Dear candidate(s)
While you would attempt to review this 1-hour lecture on Psychiatric Emergencies, try to ask yourself the
following questions and search for the appropriate answers in the lecture, or, elsewhere:
1- Which psychiatric disorder(s) present to clinician in an emergent feature more frequently?
2- Do you think that it is necessary for the psychiatric emergency room to be separated from the traditional
emergency rooms? Why?
3- What are the commonest causes of AGITATION?
4- Which EPSs do clinicians face more frequently?
5- What do you know about: Serotonin Syndrome; Lithium Toxicity; MAOIs induced Hypertensive Crisis?
6- Which over-counter pills contain psychotropic substances? Do you think that these over-counter pills are
safe?
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Psychiatric Emergencies