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