2nd Mental Health Case Manager
Workshop 2012
Psychiatric emergency:
Priorities for intervention.
Session Outline
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Psychiatric emergency:
What
Where
Who
Police Involvement
The Emergency Department
Management of acute behavioural disturbance
Psychiatric emergency.
Severe behavioural disturbance:
 Aggression
 Self harm/Suicide
 Related Medical Emergencies:
Intoxication
Side effects.
Where do psychiatric
emergencies happen?

In the community!
 In Emergency Department.
 In the inpatient unit.

Who responds?
Police
Ambulance
Community mental health
Citizens
 Why?
 What do they do?
 What should they do?
NSW Police:
Mental health
interactions
2000-2007
NSW Police Mental Health Intervention Team

Comprehensive four day training program

Police are trained in signs and symptoms of mental
illness, Ambulance procedures, risk assessment, child
and adolescent disorders, medications, personality
disorders, substance abuse, legislation and
communication techniques

2 Consumers and a carer also speak about their lives
and what is is like to live with and care for someone
with a mental illness

Role play scenarios are used to allow police to put into
practice the information they have learnt – role players
are clinical health workers
The Emergency Department
The Emergency Department
Macarthur presentations.
Role of the ED
The role of the Emergency Department is to diagnose
and treat acute and urgent illnesses and injuries.
(Peninsula health Victoria.)
The role of emergency departments is to care for
emergencies. An emergency is when an illness or
injury is serious and requires urgent attention.
SESAHS NSW)
Management of acute and urgent aspects of illness
and injury affecting patients of all age groups, with a
full spectrum of undifferentiated physical and
behavioural disorders.
(The International Federation of Emergency Medicine)
Role of the ED in psychiatric
intervention.
•
•
•
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De-escalate
Maintain safety
Assess
Treat
Factors That Determine
Response.

Level of risk:
 To self
 To others
 Level of agitation
 Length of time the patient is expected to
remain in the department.
 Stigma.
Agitation and Disturbed
Behaviours

Severe anxiety associated with motor
restlessness. (Kaplan & Sadock 1998)
 Internal tension associated with excessive
motor activity eg. Pacing, restlessness,
wringing hands, increased verbalisation,
hypervigilance,threatening manner. (Centre
for mental health 2001)
 In the context of psychotic features?
Antipsychotic Medication in
the ED

Neuroleptization
 Rapid tranquilization
 Haloperidol
 Benzodiazepines
Treatment Goals

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Prevention of harm
Controlling disturbed behaviour
Suppressing symptoms
Effecting rapid return to best level of
functioning
Developing a therapeutic alliance
Neuroleptic Side-effects

Dystonia
 Akathisia
 Neuroleptic Malignant
Syndrome
 QTc Interval
prolongation
Risperidone

2mg Risperidone + 2 mg Lorazepam
= 5mg IM Haloperidol + 2mg IM Lorazepam.
(Currier & Simpson 2001)
 Antipsychotic action at 30, 60 & 120
minute follow up intervals.
 Orthostatic Hypotension & Akathisia
apparent with rapid titration.
Olanzapine

5-20mg = or > Haloperidol for control of
psychotic symptoms & agitation.
 More sedating than other Atypicals.
 Very low risk of EPSE.
 No requirement for titration.
 Variable administration.
 IM preparation available.
Oral medication is always
first line. Lorazepam is
preferred benzodiazepine
in some services.
IM Midazolam most
common +/- Oral or IM
antipsychotic.
Droperidol is used in
some health services.
IV protocols have
changed little in the
past 20+ years.
Thanks for your Attention