DR.SOUMITRA DAS
EMERGENCY PSYCHIATRY THE PHYSICIAN DEALS WITH SITUATIONS FOR WHICH
IMMEDIATE THERAPEUTIC INTERVENTION FREQUENTLYNECESSARY.
PSYCOMOTOR AGITATIONPSYCHOMOTOR AGITATION IS DEFINED AS A STATE OF MARKEDMENTAL EXCITATION ACCOMPANIED BY PURPOSELESS MOTORACTIVITY, WHICH MAY VARY FROM SLIGHT RESTLESSNESS TOVIGOROUS UNCOORDINATED MOVEMENTS.
EPIDEMIOLOGY EQUALS 5 TO 7 % OF ALL EMERGENCIES
MORE MALES
ASSESSMENT REQUIREMENTS:
PERSONAL QUALITIES
WELL EQUIPPED UNIT(SECURITY OFFICERS,TRAINEN PERSONS)
IMPORTANT EVALUATIONS LETHALITY
SUICIDAL AND HOMICIDAL IDEATION,INTENT,ATTEMT
LEGAL RIGHT(CONSEQUENCES OF CIVIL COMMITMENTS)
FACTORS TRIGGERING HOSPITALISATION
NEED FOR CHEMICAL/PHYSICAL RESTRAINS
DESIRED FORTITUDE FOR CLINICIANS INTINCTS FOR DANGER
TOLERANCE
EMPATHY NOT SYMPATHY
SELF ASSERTION
HONESTY
RESOURSEFULLNESS AND NETWORKING
CREATIVITY
ENDURANCE
HUMOR
PRAGMATISM
SAFE ENVIRONMENT SPECIAL INTERVIEW ROOM: TWO EXIT DOORS,NO
WIRES/TUBES,CEILING NOT REACHABLE,NONREMOVABLE MATERIALS,FIVE STAFFS,VISUAL MONITORING,BOLTED DOWN FURNITURE,ISOLATION ROOM,RESTRAINS MATERIALS.
SCRENING WEAPONS
PANIC BUTTONS
CODING SYSTEM
SECURITY STAFFS NEAR ENTRANCE
INTERVIEWASSESS THE SCENEBE PREPARE TO SPEND EXTRA TIME SAFE DISTANCE,SITTING ON 45 DEG ANGLECALM ,HONESTMETHODICAL(SHOW INTEREST IN PT’S STORY)NONJUDGEMENTALRAPPORT
OPEN ENDED QUESTIONS
AVOIDING DIRECT EYE CONTACT,AVOID FRIGHTENING
EXCLUDE DISRUPTIVE PEOPLE
ENCOURAGE PURPOSEFUL MOVEMENTS
AVOIDING CHALLEGING
DEVELOP A PLAN OF ACTION.
ONCE THE PLAN IS SET, ALLOW THE PATIENT TO EXERCISE SOME CONTROL
INTERVIEW COURSE GENERAL QUESTIONS
ASSESSMENT OF DELIRIUM
SUICIDAL IDEATIONS
MEDICAL ILLNESS
PRESENT MEDICATIONS
H/O POISONING
PAST/FAMILY HISTORY/SOCIAL SUPPORT/COLLATERAL INFORMATIONS
MSE
MSE CONSCIOUSNESS
LEVEL
CONCENTRATION
ORIENTATION
YEAR/MONTH
LOCATION
ACTIVITY
APPEARANCE,BEHAVIOR
MOVEMENT
SPEECH
RATE, VOLUME, FLOW, ARTICULATION, AND INTONATION
MSE THOUGHT
IS THE PATIENT MAKING SENSE?
MEMORY
RECENT
REMOTE
IMMEDIATE
AFFECT AND MOOD
DO THE INNER FEELINGS SEEM APPROPRIATE?
PERCEPTION
“DO YOU HEAR THINGS OTHERS CAN’T?”
SECONDARY ASSESSMENT In examining the
extremities, check for:
Needle tracks
Tremors
Unilateral weakness or loss of sensation
OBTAIN VITAL SIGNS.
EXAMINE SKIN TEMPERATURE AND MOISTURE.
INSPECT THE HEAD AND PUPILS.
NOTE UNUSUAL ODORS ON THE BREATH.
ASSESSING AGITATION SHOULDN’T BE RESTRAINED OR MEDICATED IMMEDIATELY.
DETERMINE THE PT’S “RISK OF ESCALATION.”
FOUR STAGES OF AGITATION
STAGE 1: THE AGITATION IS MODIFIED BY VERBAL CUES, WITHOUT
LIMITS OR BOUNDARIES BEING INVOKED.
STAGE 2: THE AGITATION IS CONTAINED VERBALLY THROUGH LIMIT-
SETTING, BUT IT PERSISTS NONETHELESS.
STAGE 3: THE AGITATION SUBSIDES DURING TRANSIENT PHYSICAL
RESTRAINT.
STAGE 4: THE AGITATION REQUIRES PHARMACOTHERAPY. IT IS
OTHERWISE INTRACTABLE.
OFTEN STAGES 3 AND 4 ARE CONFLATED.
ALWAYS HAVE AN EXIT STRATEGY, AND ENSURE THAT
OTHERS CAN QUICKLY COME TO YOUR ASSISTANCE,
IN CASE THAT’S REQUIRED.
NEVER PLAY HERO(INE) AND TAKE THINGS INTO YOUR
OWN HANDS!
CRITERIA FOR HOSPITALISATION DANGER TO SELF/OTHER
POOR SELF CARE/BREAKDOWN OF SUPPORT SYSTEM
EXTREME DISTRESS OR CRISIS
EXACERBATION OF PSYCHIAYTRIC ILLNESS
CLARIFICATION OF DIAGNOSIS
POOR INSIGHT/JUDGEMENT
INTOXICATION
REPEATED TREATMENT FAILURE
FOR ECT
IT IS IMPORTANT TO FORMULATE A TENTATIVE DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS TO GUIDE TREATMENT.
MEDICAL CONDITIONSACUTE ONSET
FIRST EPISODE
GERIATRIC AGE
CURRENT MEDICAL ILLNESS OR INJURY
SIGNIFICANT SUBSTANCE ABUSE
NON-AUDITORY DISTURBANCES OF PERCEPTION
NEUROLOGICAL SYMPTOMS
COGNITIVE DYSFUNCTION
CONSTRUCTIONAL APRAXIA
MEDICAL AND PSYCHOLOGICAL CONDITIONS THAT MAY PRESENT WITH VIOLENT BEHAVIOR
Medical Substance Induced
CEREBRAL INFECTION
CEREBRAL NEOPLASM
ELECTROLYTE IMBALANCE
HEPATIC DISEASE
HYPOGLYCAEMIA
HYPOXIA
INFECTION
RENAL DISEASE
TEMPORAL LOBE EPILEPSY
VITAMIN DEFICIENCY
ALCOHOLIC INTOXICATION
ALCOHOL WITHDRAWAL
AMPHETAMINE INTOXICATION
COCAINE INTOXICATION
DELIRIUM TREMENS
INHALANT INTOXICATION
PHENCYCLIDINE (PCP) INTOXICATION
SEDATIVE/HYPNOTIC WITHDRAWAL
PSYCHIATRIC ANTISOCIAL PERSONALITY DISORDER
BIPOLAR DISORDER
BORDERLINE PERSONALITY DISORDER
CATATONIC SCHIZOPHRENIA
DECOMPENSATING OBSESSIVE COMPULSIVE PERSONALITY DISORDER
DELUSIONAL DISORDER
DISSOCIATIVE DISORDER
IMPULSE CONTROL DISORDER
PARANOID PERSONALITY DISORDER
SCHIZOPHRENIA
SOCIAL MALADJUSTMENT WITHOUT PSYCHIATRIC DISORDERS
UNCONTROLLABLE VIOLENCE SECONDARY TO INTERPERSONAL STRESS
IMPORTANT CONSIDERATIONS IN DIAGNOSIS OF A VIOLENT BEHAVIOR IN PATIENT
1. PATIENT’S PREMORBID PERSONALITY
2. PAST HISTORY
3. THE UNDERLYING DISORDER
4. THE SOCIAL SETTING
PHYSICAL AND PSYCHOLOGICAL CONDITIONS THAT PRESENT WITH ALTERED MOOD.
PHYSICAL
ALCOHOL INTOXICATION
ANTIHYPERTENSIVE MEDICATION (E.G., METHYLDOPA, PROPRANOLOL, RESERPINE TOXICITY)
ANTIDEPRESSANT MEDICATION
BENZODIAZEPINE INTOXICATION
CARCINOMA OF PANCREAS
CEREBRAL TUBERCULOSIS
CEREBROVASCULAR SYPHILIS
CESSATION OF AMPHETAMINE OR COCAINE USE
CIRRHOSIS OF THE LIVER
CORTICOSTEROID TOXICITY
DEGENERATIVE DISEASES OF THE CENTRAL NERVOUS SYSTEM (E.G., ALZHEIMER’S DISEASE, HUNTINGTON’S CHOREA, PICK’S DISEASE)
DIABETES
ENCEPHALITIS
HEPATIC FAILURE
HEPATITIS
HYPERPARATHYROIDISM
HYPERTHYROIDISM
HYPOKALEMIA
HYPONATREMIA
HYPOTHYROIDISM
INFECTIOUS MONONUCLEOSIS
MULTIPLE SCLEROSIS
POSTVIRAL INFECTION SYNDROME
RENAL FAILURE
SUBDURAL HEMATOMA
PSYCHOLOGICALSCHIZOPHRENIA
BIPOLAR MOOD ILLNESS
REACTIVE DEPRESSION
REACTIVE PSYCHOSIS
SCHIZOAFFECTIVE
PHYSICAL AND PSYCHOLOGICAL ILLNESS THAT PRESENT WITH ANXIETYMedical
ALCOHOL WITHDRAWAL AMINOPHYLLINE USE AMPHETAMINE AND
SIMILAR SYMPATHAMIMETIC ANTIDEPRESSANT
WITHDRAWAL ANTIPSYCHOTIC DRUG
WITHDRAWAL BENZODIAZEPINE
WITHDRAWAL CAFFEINE INTOXICATION
DELIRIUM
ENCEPHALITIS
HYPERTENSION
HYPERTHYROIDISM
HYPOCALCAEMIA
HYPOGLYCEMIA
HYPOKALEMIA
IMPENDING MYOCARDIAL INFARCTION
INTERNAL HEMORRHAGE
LEAD INTOXICATION
OPIATE WITHDRAWAL
POST CONCUSSION SYNDROME
TEMPORAL LOBE DISEASE
PSYCHOLOGICAL
ADJUSTMENT DISORDER WITH ANXIOUS MOOD
AGORAPHOBIA WITH PANIC ATTACKS
AGORAPHOBIA WITHOUT PANIC ATTACKS
BIPOLAR MOOD ILLNESS
BORDERLINE PERSONALITY
EGO-DYSTONIC HOMOSEXUALITY
GENERALIZED ANXIETY DISORDER
HOMOSEXUAL PANIC
HYPERVENTILATION SYNDROME
OBSESSIVE-COMPULSIVE DISORDER
POST-TRAUMATIC STRESS DISORDER
SCHIZOPHRENIA
SOCIAL PHOBIA
Physical and Psychological Conditions That Present with Disorganization of Thought
Medical
ALCOHOL WITHDRAWAL AMPHETAMINE INTOXICATION ANTICONVULSANT
WITHDRAWAL ANTIDEPRESSANT
MEDICATION BACTERIAL MENINGITIS COCAINE INTOXICATIONDELIRIUM HYPERPARATHYROIDISM HYPERTHYROIDISM HYPOPARATHYROIDISM
HYPOTHYROIDISM
LEAD INTOXICATION
MERCURY INTOXICATION
MIGRAINE HEADACHE
MULTIPLE SCLEROSIS
STEROID TOXICITY
SUBDURAL HEMATOMA
SYSTEMIC LUPUS ERYTHEMATOSUS
TEMPORAL LOBE EPILEPSY
PSYCHOLOGICAL
ADJUSTMENT REACTION OF ADOLESCENCE
BIPOLAR MOOD ILLNESS
CATATONIC SCHIZOPHRENIA
CHRONIC UNDIFFERENTIATED SCHIZOPHRENIA
PARANOID SCHIZOPHRENIA
REACTIVE PSYCHOSIS
SCHIZOAFFECTIVE DISORDERS
SCHIZOPHRENIFORM DISORDERS
MANAGEMENT OF BEHAVIORAL EMERGENCIES
ENVIRONMENTAL PROTOCOL
PERIODIC TRAINING
RECYCLING
SECURITY
ALTITUDINAL AVOID ABRUPT MOVEMENTS
AVOID TAKING NOTES
OWN INTRODUCTION WITH REASSURANCE
ENCOURAGE TO EXPRESS FEELINGS
LIMIT OF ACCEPTING MANNER
PHARMACOLOGICAL:PRELIMINARY CONSIDERATIONS PM AGITATION
ASSESSMENT
GROUP APPOARCH
DESCRIBE REASON FOR MEDICATIONS
ORAL>PARENTERAL
AGE/SEX
MEDICAL ILLNESS/CI
PREGNANCY
BMI
H/O MEDICATIONS/SIDE EFFECTS
DRUGSBENZODIAZEPINES CATIONS
LORAZEPAM 1 OR 2 MG,PO/IM/IV
FAST ACTING,
EASY,DOSING,ABSORPTION
NO ACTIVE METABOLITES
NO GLUCURONIDATION
COPD
SLEEP APNEA
ANTIPSYCHOTICSHALOPERIDOL DROPERIDOL
TYPICAL
HIGH POTENCY
CAN BE COMBINED LORAZEPAM
TO AVOID S/E:COMBINE WITH TRIHEXYPHENIDRYL/BENZTROPINE/DIPHENHYDRAMINE
SEDATION MORE RAPID
PROLONG QT INTERVAL
DOSING OF TYPICALS CHLORPROMAZINE[DAILY PO50-400/INITIAL IM 25-
50MG]
FLUPHENAZINE[DAILY PO2-20MG/INITIAL IM1.25-5MG]
HALOPERIDOL[DAILY PO2.5-100/INITIAL IM2.5-10MG]
MESORIDAZINE[DAILY PO100-400/INITIAL IM25-50MG]
PERPHENAZINE[DAILY PO16-64/INITIAL IM5-10MG]
THIOTHIXENE[DAILY PO15-60/INITIAL IM4-8 MG]
TRIFLUOPERAZINE[DAILY PO4-20/INITIAL IM1-2MG]
ATYPICALS OLANZAPINE[30MG/DAY] IM
ZIPRASIDONE[40MG/DAY] IM
RISPERIDONE 0.25-8 MG/DAY PO,IM LA
QUETIAPINE 25-800/DAY PO
ARIPIPRAZOLE 10-30MG/DAY PO
CLOZAPINE 200-1000MG/DAY
PHYSICAL RESTRAINT IMPROVISED OR COMMERCIALLY MADE DEVICES
BE FAMILIAR WITH RESTRAINTS USED BY YOUR AGENCY
MAKE SURE YOU HAVE SUFFICIENT PERSONNEL
MINIMUM OF FIVE TRAINED, ABLE-BODIED PEOPLE
DISCUSS THE PLAN OF ACTION BEFORE YOU BEGIN
INCLUDE LAW ENFORCEMENT
USE THE MINIMUM FORCE NECESSARY
DON’T IMMEDIATELY MOVE TOWARD THE PATIENT
DO NOT TIE ANKLES AND WRISTS TOGETHER
HOBBLE TIE
PLACE A PATIENT FACEDOWN IN A REEVES STRETCHER
ONCE IN PLACE DON’T REMOVE RESTRAINTS.
DON’T NEGOTIATE OR MAKE DEALS.
PLACE A MASK OVER THE FACE OF A SPITTING PATIENT.
CONTINUOUSLY MONITOR THE PATIENT.
NEVER PLACE YOUR PATIENT FACE DOWN.
CHECK PERIPHERAL CIRCULATION EVERY FEW MINUTES.
ADVERSE EFFECT CAN PRESENT WITH AGITATION
SEROTONIN SYNDROME NEUROLEPTIC MALIGNANT SYNDROME
CAUSES-SSRI,SNRI,COMBINATIONS OF MULTIDRUGS
DIARRHEA/CONFUSION/DELIRIUM/COMA/INSTABLE ANS/TREMOR/RIGITY/MYOCLONUS/AKI/DIC/ARDS/SEIZURE
RFT/LFT/CPK/ECG/CBC/INR
RX:DISCONTINUE DRUGS/IVF/BDZ/ICU
ANTIPSYCHOTICS
HTN/DIAPHORESIS/TACHYCARDIA/LIVER FAILURE/AKI/MYOCLONUS/CONFUSION/TREMOR/RIGIDITY/ATAXIA
SEROLOGIC MARKERS INCLUDE ELEVATED CK, DEMONSTRATING RHABDOMYOLYSIS; METABOLIC ACIDOSIS; AND LEUKOCYTOSIS
RX:DISCONTINUATION/IVF/DANTROLENE/BROMOCRIPTINE/AMANTIDINE/LEVODOPA/BENZTROPINE/CLONAZEPAM/ECT
LITHIUM TOXICITY
ASSOCIATED WITH NAUSEA, VOMITING, DIARRHEA, WEAKNESS, FATIGUE, LETHARGY, CONFUSION, SEIZURE, AND POTENTIALLY COMA
TOXICITY NOT ENTIRELY CORRELATED WITH SERUM LITHIUM LEVEL; TOXICITY MAY DEVELOP AT DIFFERENT LEVELS FOR DIFFERENT PEOPLE
OBTAIN SERUM LITHIUM LEVEL, AND EKG
ENCOURAGE HYDRATION; CONSIDER HEMODIALYSIS IN EXTREME CASES
SPECIFIC SITUATIONSSUICIDE: ANY WILLFUL ACT DESIGNED TO END ONE’S LIFE
Suicide Risk Factors PREVIOUS ATTEMPTS DEPRESSION AGE
15–24 OR OVER 40
ALCOHOL OR DRUG ABUSE DIVORCED OR WIDOWED GIVING AWAY BELONGINGS LIVING ALONE OR IN
ISOLATION PRESENCE OF PSYCHOSIS WITH
DEPRESSION MANIA F20 HOMOSEXUALITY
HIV STATUS
MAJOR SEPARATION TRAUMA
MAJOR PHYSICAL STRESSES
LOSS OF INDEPENDENCE
LACK OF GOALS AND PLAN FOR THE FUTURE
SUICIDE OF SAME-SEXED PARENT
EXPRESSION OF A PLAN FOR SUICIDE
POSSESSION OF THE MECHANISM FOR SUICIDE
SUICIDAL IDEATION ASSESSMENT
EVERY DEPRESSED PATIENT MUST BE EVALUATED FOR SUICIDE RISK.
MOST PATIENTS ARE RELIEVED WHEN THE TOPIC IS BROUGHT UP.
BROACH THE SUBJECT IN A STEPWISE FASHION.
DIAGNOSE HIGHER-RISK PATIENTS
DON’TS
DON’T LECTURE, BLAME OR PREACH
DON’T CRITICIZE CLIENT
DON’T DEBATE THE PROS AND CONS OF SUICIDE
DON’T BE MISLED BY CLIENT’S TELLING YOU THE CRISIS HAS PASSED
DON’T DENY THE CLIENT’S SUICIDAL IDEAS
DON’T TRY TO CHALLENGE
DON’T LEAVE CLIENT ISOLATED, UNOBSERVED OR DISCONNECTED
DON’T DIAGNOSE AND ANALYZE BEHAVIOR OR CONFRONT PERSON WITH INTERPRETATIONS DURING ACUTE PHASE
DON’T BE PASSIVE
DON’T OVER REACT
DON’T KEEP CLIENT’S SUICIDAL RISK A SECRET
DON’T GET SIDE TRACKED ON EXTERNAL ISSUES OR PERSONS
DON’T GLAMORIZE, MARTYRIZE, GLORIFY OR DEFY SUICIDAL BEHAVIOR IN OTHERS, PAST OR PRESENT
DON’T FORGET TO TREAT THE PSYCHIATRIC ILLNESS DON’T FORGET TO FOLLOW UP
HOMICIDALITY
RISK FACTORS:
HISTORY OF VIOLENCE; AGGRESSION
IMPULSIVITY; INTOXICATION
SINCERE PLAN
COMMON ETIOLOGIES INCLUDE:
PSYCHOSIS (COMMAND AHS); AFFECTIVE DISORDERS; PERSONALITY VULNERABILITIES; SUBSTANCE INTOXICATION OR WITHDRAWAL
MANAGEMENTS
CLARIFY THREAT TO OTHER(S)
IF THREAT IS DEEMED SERIOUS
NOTIFY POLICE
MAKE EFFORTS TO WARN INDIVIDUAL(S) (TARASOFF RULING)
ADMIT PT UNTIL THREAT SUBSIDES
DON’T HESITATE TO ADMIT INVOLUNTARILY EVEN IF PRECISE PSYCHIATRIC DIAGNOSIS REMAINS ELUSIVE IN THE END
AGITATED DELIRIUM FLUCTUATING SENSORIUM SUICIDAL AND HOMICIDAL
RISK COGNITIVE CLOUDING VISUAL, TACTILE, AND
AUDITORY HALLUCINATIONS PARANOIA
EVALUATE ALL POTENTIAL CONTRIBUTING FACTORS AND TREAT EACH ACCORDINGLY
REASSURANCE, STRUCTURE, CLUES TO ORIENTATION
BENZODIAZEPINES HIGH-POTENCY
ANTIPSYCHOTICS MUST BE USED WITH EXTREME CARE BECAUSE OF THEIR POTENTIAL TO ACT PARADOXICALLY AND INCREASE AGITATION
ALCOHOL DEPENDENCE AND DELIRIUM
CONFUSION, DISORIENTATION, FLUCTUATING CONSCIOUSNESS AND PERCEPTION, AUTONOMIC HYPERACTIVITY; MAY BE FATAL
BDZ
THIAMINE
MET
ANTICRAVING
GERIATRIC BEHAVIORAL PROBLEMS DISTRESS AND PAIN MAY BE
CAUSED BY:
EXPOSURE TO NEW EXPERIENCES
ALTERATIONS TO ROUTINES
ANXIETY AND DEPRESSION ARE TOO OFTEN CONSIDERED A “NORMAL PART OF AGING.”
AGEISM: DISCRIMINATION AGAINST OLDER PEOPLE
PEDIATRIC BEHAVIORAL PROBLEMS 50% OF CHILDHOOD
MENTAL ILLNESSES WILL PRESENT BY AGE 14 YEARS.
MORE LIKELY TO HAVE COEXISTING PROBLEMS
DIFFICULT TO DIAGNOSE
MENTAL STATUS ASSESSMENT IS SIMILAR TO THAT OF AN ADULT.
EXCEPTION: CONSIDER DEVELOPMENTAL LEVEL.
ABNORMAL FINDINGS ARE OFTEN RELATED TO ADJUSTMENT DISORDERS AND STRESS.
MANAGEMENT AVOID SEPARATING YOUNG
CHILDREN FROM THEIR PARENT.
PREVENT CHILDREN FROM SEEING THINGS THAT WILL INCREASE THEIR DISTRESS.
MAKE ALL EXPLANATIONS BRIEF AND SIMPLE.
BE CALM AND SPEAK SLOWLY.
IDENTIFY YOURSELF.
BE TRUTHFUL WITH CHILDREN.
ENCOURAGE CHILDREN TO HELP WITH THEIR CARE
REASSURE CHILDREN BY CARRYING OUT ALL INTERVENTIONS GENTLY.
DO NOT DISCOURAGE CHILDREN FROM CRYING OR SHOWING EMOTIONS.
IF YOU WILL BE SEPARATED FROM CHILDREN, INTRODUCE THE NEXT PERSON WHO WILL ASSUME THEIR CARE.
ALLOW CHILDREN TO KEEP A FAVORITE BLANKET OR TOY.
DO NOT LEAVE CHILDREN ALONE.
ABUSE OF CHILD OR ADULT
SIGNS OF PHYSICAL TRAUMA
MANAGEMENT OF
MEDICAL PROBLEMS
ADOLESCENT CRISES
SUICIDAL ATTEMPTS AND IDEATION
SUBSTANCE ABUSE
TRUANCY, TROUBLE WITH LAW
PREGNANCY
RUNNING AWAY
EATING DISORDERS
PSYCHOSIS
EVALUATION OF SUICIDALPOTENTIAL
EXTENT OF SUBSTANCE ABUSE
FAMILY DYNAMICS
CRISIS-ORIENTED FAMILY AND INDIVIDUAL THERAPY
HOSPITALIZATION IF NECESSARY
CONSULTATION WITH APPROPRIATE EXTRAFAMILIAL AUTHORITIES
BORDERLINE PERSONALITY DISORDER SUICIDAL IDEATION AND
GESTURES
HOMICIDAL IDEATIONS AND GESTURES
SUBSTANCE ABUSE
MICRO PSYCHOTIC EPISODES
BURNS, CUT MARKS ON BODY
SUICIDAL AND HOMICIDAL EVALUATION (IF GREAT, HOSPITALIZATION)
SMALL DOSAGES OF ANTIPSYCHOTICS
CLEAR FOLLOW-UP PLAN
BRIEF PSYCHOTIC DISORDER
EMOTIONAL TURMOIL
EXTREME LABILITY
ACUTELY IMPAIRED REALITY TESTING AFTER OBVIOUS PSYCHOSOCIAL STRESS
HOSPITALIZATION OFTEN NECESSARY
LOW DOSAGE OF ANTIPSYCHOTICS MAY BE NECESSARY BUT OFTEN RESOLVES SPONTANEOUSLY
CATATONIC SCHIZOPHRENIA
MARKED PSYCHOMOTOR DISTURBANCE (EITHER EXCITEMENT OR STUPOR)
EXHAUSTION
CAN BE FATAL
RAPID TRANQUILIZATION WITH ANTIPSYCHOTICS
MONITOR VITAL SIGNS
AMOBARBITAL MAY RELEASE PATIENT FROM CATATONIC MUTISM STUPOR BUT CAN PRECIPITATE VIOLENT BEHAVIOR
LORAZEPAM CAN BE USED
DELUSIONAL DISORDER
MOST OFTEN BROUGHT IN TO EMERGENCY ROOM INVOLUNTARILY; THREATS DIRECTED TOWARD OTHERS
ANTIPSYCHOTICS IF PATIENT WILL COMPLY (IM IF NECESSARY)
INTENSIVE FAMILY INTERVENTION
HOSPITALIZATION IF NECESSARY
DEMENTIA UNABLE TO CARE FOR SELF
VIOLENT OUTBURSTS
PSYCHOSIS
DEPRESSION AND SUICIDAL IDEATION
CONFUSION
SMALL DOSAGES OF HIGH-POTENCY ANTIPSYCHOTICS
CLUES TO ORIENTATION
ORGANIC EVALUATION, INCLUDING MEDICATION USE
FAMILY INTERVENTION
DEPRESSIVE DISORDERS
SUICIDAL IDEATION AND ATTEMPTS
SELF-NEGLECT
SUBSTANCE ABUSE
ASSESSMENT OF DANGER TO SELF
HOSPITALIZATION IF NECESSARY
NONPSYCHIATRIC CAUSES OF DEPRESSION MUST BE EVALUATED
Panic disorder
PANIC, TERROR; ACUTE ONSET
MUST DIFFERENTIATE FROM OTHER ANXIETY-PRODUCING DISORDERS, BOTH MEDICAL AND PSYCHIATRIC; ECG TO RULE OUT MITRAL VALVE PROLAPSE
ALPRAZOLAM (0.25 TO 2.0 MG); LONG-TERM MANAGEMENT MAY INCLUDE AN ANTIDEPRESSANT
HOMOSEXUAL PANIC ADAMANTLY DENY
HAVING ANY HOMOEROTIC IMPULSES
AROUSED BY TALK, A PHYSICAL OVERTURE
PLAY AMONG SAME-SEX FRIENDS
PANICKED PERSON SEES OTHERS AS SEXUALLY INTERESTED IN HIM
VENTILATION,
ENVIRONMENTAL
STRUCTURING
BDZ/ ANTIPSYCHOTICS MAY
BE REQUIRED
OPPOSITE-SEX CLINICIAN
SHOULD EVALUATE THE
PATIENT WHENEVER POSSIBLE
INTOXICATIONS ALCOHOL INTOXICATION ANTICHOLINERGIC
INTOXICATION ANTICONVULSANT
INTOXICATION BENZODIAZEPINE
INTOXICATION CAFFEINE INTOXICATION CANNABIS INTOXICATION
COCAINE INTOXICATION AND WITHDRAWAL
L-DOPA INTOXICATION
OPOID INTOXICATIONS
BROMIDE INTOXICATION
RAPE AND SEXUAL ASSAULTAN UNEXPECTED AND VIOLENT THREAT ON ONE’S LIFE.
IT IS A LOSS, VIOLATION AND INSTANT DEMORALIZATION.
TYPICAL REACTIONS INCLUDE SHAME, HUMILIATION, ANXIETY, CONFUSION AND OUT RAGE.
MANAGEMENT1. STAY WITH THE PATIENT THE ENTIRE TIME IN THE E.R.
2.EXPLANATIONS FOR SPECIFIC DATA THAT IS NEEDED.
3. CONSENT FOR EXAMINATION AND SPECIMEN COLLECTION
4. PATIENT AND CONSIDERATE. NEVER PRESS OR HARASS THE PATIENT FOR ANSWERS.
5.ANSWER THE PATIENT’S QUESTIONS AND FREQUENT REASSURANCE THAT THE PATIENT IS IN A SAFE PLACE.
6.THE PATIENT MUST BE GIVEN TIME AND DATE TO MAKE HER OWN DECISION ABOUT THE LEGAL PROCESS.
7. EDUCATE THE PATIENT ABOUT THE RAPE TRAUMA SYNDROME.
8. CALL THE PATIENT 48HOURS LATER AND THEN WEEKLY FOR FOLLOW UP.
9. ON LATER STAGES, PROVIDE COUNSELING WITH REALISTIC ISSUES SUCH AS WORK, HOME, LEGAL DIFFICULTIES, SHARING OF EMOTION, FUTURE REHABILITATION.
CRISIS INTERVENTION UNEXPECTED SERIES OF EVENT
DANGER OR OPPORTUNITY
PHYSICAL,PSYCHOLOGICAL,INTERPERSONAL
DEVELOPMENTAL,SITUATIONAL
ABC MODEL ACHIEVING RAPPORT
BEGINNING OF PROBLEM IDENTIFICATION
COPING
DEATH AND DYING DENIAL AND ISOLATION
ANGER
BARGAINING
DEPRESSION
ACCEPTANCE
LEGAL ISSUES IN EMERGENCY PSYCHIATRY CONFIDENTIALITY
DUTY TO WARN
COMPETENCY
INFORMED CONSENT
INVOLUNTARY COMMITMENT
BEHAVIORAL EMERGENCIES CAN PRESENT UNIQUE CHALLENGES IN PATIENT MANAGEMENT. FOCUS ON REDUCING THE PATIENT’S STRESS WITHOUT EXPOSING OWNSELF TO UNNECESSARY RISKS.
OUR GREATEST WEAKNESS LIES IN GIVING UP. THE MOST CERTAIN WAY TO SUCCEED IS ALWAYS TO TRY
JUST
ONE MORE TIME.
-THOMAS EDISON
REFERENCES Kaplan & sadock's comprehensive textbook of
psychiatry, 9th edition
Emergency psychiatry by Hani raoul khouzam,Doris tiu tan,Tirath sing gill
THANKING YOU
Top Related