PSYCHIATRIC EMERGENCIES Dr. Rabie Hawari Consultant Psychiatrist Clinical Assistant Professor

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 mg.

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), /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 ) mg 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 mg im. Droperidol 10-20mg im or iv.. Clopixol Aquaphase mg 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 3 rd.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.