Psychiatry Emergency

DR.
JAYESH PATI DAR

Psychiatric
Emergencies
National EMS Education Standard Competencies
Psychiatric
Recognition of
Behaviors that pose a risk to the EMS provider, patient, or
others
Assessment and management of
Basic principles of the mental health system
Suicidal/risk
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www.drjayeshpatidar.blogspot.com
Anatomy, physiology, epidemiology, pathophysiology,
psychosocial impact, presentations, prognosis, and
management of
Acute psychosis
Agitated delirium
Cognitive disorders
Thought disorders
Mood disorders
Neurotic disorders
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Anatomy, physiology, epidemiology, pathophysiology,
psychosocial impact, presentations, prognosis, and
management of (contd)
Substance-related disorders/addictive behavior
Somatoform disorders
Factitious disorders
Personality disorders
Patterns of violence/abuse/neglect
Organic psychoses
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Introduction
The mind and body are inseparable.
Illness affects a persons behavior.
Changes in mental state affect physical health.
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Definition of Behavioral Emergency
Most experts define behavior as the way people act
or perform.
Overt behavior is generally understood by those around the
person.
Covert behavior has hidden meanings or intentions.
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Behavioral emergency
Some disorder of mood,
thought, or behavior
that interferes with
ADLs
Psychiatric emergency
Behavior that threatens
a persons health or
safety and the health
and safety of another
person
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A behavioral or psychiatric emergency is defined by
the person who dials 9-1-1.
It can be difficult to understand the patients
confused and frayed feelings.
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Prevalence
Average number of mentally unhealthy days for
Americans has increased
1993: 2.9 days/month
Today: 3.5 days/month
45.1 million US adults with any mental illness in the
past year
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Medicolegal Considerations
When behavior, speech, and thoughts are erratic, it
can be difficult to communicate.
Spend time with the patient.
Obtain consent when possible.
Be clear in your explanations.
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Causes of Abnormal Behavior
Four broad categories
Biologic or organic in nature
Resulting from the environment
Resulting from acute injury or illness
Substance-related
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Biologic or organic
Organic brain syndrome
Conditions alter the functioning of the brain
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Environmental
Psychosocial and sociocultural influences
When consistently exposed to stressful events patients develop
abnormal reactions.
Sociological factors affect biology, behavior, and responses to the
stress of emergencies.
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Injury and illness
Illness results in stress
on coping mechanisms.
Acute trauma creates
stress.
Post-traumatic stress
disorder (PTSD)
Courtesy of Captain David Jackson, Saginaw Township Fire Department
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Substance-related
Alcohol
Cigarettes
Illicit drugs
Other substances
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Psychiatric Signs and Symptoms
When mental health is challenged, mechanisms or
behaviors work to return homeostasis.
Present as psychiatric signs and symptoms
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Psychiatric Signs and Symptoms
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Patient Assessment
Assessment of the patient with a behavioral
emergency differs from other methods.
You are the diagnostic instrument.
The assessment is part of the treatment.
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Scene Size-Up
Situations with a strong behavioral component may
have a sudden and unexpected turn of events.
Determine whether it is dangerous to you and your partner.
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Scene Size-Up
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Scene Size-Up
The environment can give clues.
Social history
Living conditions
Availability of support
Activity level
Medications
Overall appearance
Attitude/well-being
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Primary Assessment
Clearly identify yourself.
Form a general impression.
Assess appearance, posture, and pupils.
Limit the number of people around the patient.
Stay alert to potential danger.
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Primary Assessment
Airway and breathing
Assess the airway and evaluate breathing.
Provide interventions based on your findings.
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Primary Assessment
Circulation
Assess the pulse rate, quality, and rhythm.
Obtain systolic and diastolic blood pressures.
Evaluate for shock and bleeding.
Assess the patients perfusion level.
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Primary Assessment
Transport decision
Disturbed patients should see a physician.
If a patient withholds consent, they may be taken against their
will at the request of:
Police
County mental health physician
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Primary Assessment
Transport decision (contd)
The same applies to the use of forcible restraint.
Law enforcement officers should be summoned.
Consult medical command as necessary.
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History Taking
Mental status
examination
Key part of assessment
Check each system using
COASTMAP.
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COASTMAP
Consciousness
Level
Concentration
Orientation
Year/month
Location
Activity
Behavior
Movement
Speech
Rate, volume, flow,
articulation, and
intonation
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COASTMAP
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 cant?
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Secondary Assessment
Obtain vital signs.
Examine skin temperature and moisture.
Inspect the head and pupils.
Note unusual odors on the breath.
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Secondary Assessment
In examining the extremities, check for:
Needle tracks
Tremors
Unilateral weakness or loss of sensation
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Reassessment
Routinely performed during transport
Your radio report should include:
Medical and mental health history
Medications prescribed
Assessment findings
Information from the mental status examination
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Reassessment
Discuss with the hospital the need for restraints or
medications.
If the patient is aggressive or violent, provide advance notice to
the emergency department.
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Emergency Medical Care
If the erratic behavior could be caused by a medical
disorder:
Treat that before presuming the behavior is due to an
emotional or psychiatric cause.
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Communication Techniques
Begin with an open-
ended question.
Let the patient talk.
Listen, and show that
you are listening.

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Dont be afraid of
silences.
Acknowledge and label
feelings.
Dont argue.
Facilitate
communication.
Direct the patients
attention.
Confrontation
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Ask questions.
Avoid yes-no or leading questions.
Use how and what questions.
Adjust your approach as needed.
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Crisis Intervention Skills
Be as calm and direct
as possible.
Exclude disruptive
people.
Sit down.
Preferably at a
45-degree angle
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Maintain a
nonjudgmental
attitude.
Provide honest
reassurance.
Develop a plan of
action.
Once the plan is set,
allow the patient to
exercise some control.
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Encourage some motor activity.
Stay with the patient at all times.
Bring all medications to the hospital.
Never assume that it is impossible to talk with any
patient until you have tried.
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Physical Restraint
Improvised or commercially made devices
Be familiar with restraints used by your agency.
Make sure you have sufficient personnel.
Minimum of four trained, able-bodied people
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Physical Restraint
Discuss the plan of action before you begin.
Include law enforcement.
Use the minimum force necessary.
Dont immediately move toward the patient.
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Physical Restraint
If the show of force doesnt calm the patient, move
quickly.
Grasp at the elbows, knees, and head.
Apply restraints to all four extremities.
The best position is supine.
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Physical Restraint
Never:
Tie ankles and wrists
together
Hobble tie
Place a patient facedown
in a Reeves stretcher
Once in place:
Dont remove restraints.
Dont negotiate or make
deals.
Place a mask over the
face of a spitting patient.
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Physical Restraint
Continuously monitor
the patient.
Never place your
patient face down.
Check peripheral
circulation every few
minutes.
Jones & Bartlett Learning. Courtesy of MIEMSS.
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Physical Restraint
Be careful if a combative patient suddenly becomes
calm.
Document everything in the patients chart.
You may defend yourself against an attack.
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Chemical Restraint
Use of medication to subdue a patient
Only use with approval from medical control
Follow local protocols and guidelines.
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Chemical Restraint
Haloperidol
Administered either IM or IV
Should not be administered to:
Patients younger than 14 years
Those with a suspected head injury
Those who may be pregnant
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Chemical Restraint
Benzodiazepines
Shorter-acting ones may be given intranasally.
Only midazolam and lorazepam have reliable intramuscular
absorption.
Side effects are usually mild and easily treated.
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Chemical Restraint
Closely monitor the patients:
Pulse rate
Blood pressure
Respiratory rate
Be prepared to support ventilation.
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Pathophysiology, Assessment, and Management of
Specific Emergencies
Many factors
contribute to
disturbances of
behavior.
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Acute Psychosis
Pathophysiology
Person is out of touch with reality
Occur for many reasons
Episodes can be brief or last a lifetime.
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Acute Psychosis
Assessment
Characteristic: profound thought disorder
A thorough examination is rarely possible.
Transport the patient in an atraumatic fashion.
Use COASTMAP.
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Acute Psychosis
Consciousness
Awake and alert
Easily distracted
Orientation
Disturbances more
common in organic
disorders
Activity
Most commonly
accelerated
Speech
Neologisms
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Acute Psychosis
Thought
Disturbed in progression
and content
Memory
Relatively or entirely
intact
Affect and mood
Mood is likely to be
disturbed.
Affect may reflect mood
or be flat.
Perception
Auditory hallucinations
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Acute Psychosis
Management
Reasoning doesnt always work.
Explain what is being done.
Directions should be simple and consistent.
Keep orienting the patient.
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Acute Psychosis
Management (contd)
Before pharmacologic treatments, try:
Maintaining an emotional distance
Explaining each step of the assessment
Involving people the patient trusts
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Acute Psychosis
Management (contd)
When methods fail, it may be appropriate to:
Safely restrain the patient.
Administer a medication to help the behavior.
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Agitated Delirium
Pathophysiology
Delirium: a state of global cognitive impairment
Dementia: more chronic process
Patients may become agitated and violent.
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Agitated Delirium
Assessment
Try to reorient patients.
Perform a thorough assessment.
Management
Identify the stressor or metabolic problem.
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Suicidal Ideation
Pathophysiology
Suicide: any willful act designed to end ones life
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Suicidal Ideation
Assessment
Every depressed patient
must be evaluated for
suicide risk.
Most patients are
relieved when the topic is
brought up.
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Suicidal Ideation
Assessment (contd)
Broach the subject in a stepwise fashion.
Higher-risk patients include patients who have:
Made previous attempts
Detailed, concrete plans
A history of suicide among close relatives
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Suicidal Ideation
Management
Dont leave the patient alone.
Collect implements of self-destruction.
Acknowledge the patients feelings.
Encourage transport.
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Patterns of Violence, Abuse, and Neglect
Abuse and neglect
Assess the following:
The patient
The environment
Other persons involved
Document your findings, and report your concerns according
to local protocols.
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Violence
Most angry patients can be calmed by a trained person who
conveys confidence.
EMS personnel should prepare to deal with hostile or violent
behavior.
Preventive action is best to ensure no harm.
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Identify situations with the potential for violence.
Preventive action starts with being prepared for a possible
violent encounter.
Develop survival awareness.
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Risk factors
Scenarios including:
Alcohol or drug consumption
Crowd incidents
Violence has already
occurred
People who are:
Intoxicated
Experiencing withdrawal
Psychotic
Delirious
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Warning signs include:
Posture: sitting tensely
Speech: loud, critical, threatening
Motor activity: unable to sit still, easily startled
Clenched fists, avoidance of eye contact
Your own feelings
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Management of the violent patient
Assess the whole situation.
Observe your surroundings.
Maintain a safe distance.
Try verbal interventions first.
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Mood Disorders
Unipolar mood disorder: mood remains at one pole
of the continuum
Bipolar mood disorder: mood alternates between
mania and depression
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Mood Disorders
Manic behavior
Patients typically have abnormally exaggerated happiness with
hyperactivity and insomnia.
Pressured and rapid speech
Tangential thinking
Grandiose and unrealistic ideas
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Mood Disorders
Manic behavior (contd)
Be calm, firm, and patient.
Minimize external stimulation.
If the patient refuses transport, consult medical control.
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Mood Disorders
Depression
Leading cause of disability in people 15- to
44-year olds
Can occur in episodes with sudden onset and limited duration
Onset can also be insidious and chronic.
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Mood Disorders
Depression (contd)
Diagnostic features (GAS PIPES)
Guilt
Appetite
Sleep disturbance
Paying attention
Interest
Psychomotor abnormalities
Energy
Suicidal thoughts
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Schizophrenia
Typical onset occurs during early adulthood.
Experience may include:
Delusions
Hallucinations
A flat affect
Erratic speech
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Neurotic Disorders
Collection of psychiatric disorders without psychotic
symptoms
Includes anxiety disorders
Mental disorders in which dominant moods are fear and
apprehension
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Neurotic Disorders
Generalized anxiety disorder (GAD)
Patient worries for no particular reason or worrying prevents
decision-making abilities.
Treated with pharmacologic agents and counseling
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Neurotic Disorders
Generalized anxiety disorder (GAD) (contd)
When dealing with a patient with GAD:
Identify yourself in a calm, confident manner.
Listen attentively.
Talk with the person about their feelings.
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Neurotic Disorders
Phobias
Unreasonable fear, apprehension, or dread of a specific
situation or thing
Simple phobias focus all anxieties on one class of objects or
situations.
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Neurotic Disorders
Phobias (contd)
When managing a patient, explain each step of treatment in
detail.
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Neurotic Disorders
Panic disorder
Sudden feelings of fear and dread
If allowed to continue, panic attacks can cause severe lifestyle
restrictions.
Agoraphobia: fear of going into public places
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Neurotic Disorders
Panic disorder
(contd)
Signs and symptoms
usually peak in
10 minutes.
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Neurotic Disorders
Panic disorder (contd)
Separate from panicky bystanders.
Provide a calm environment.
Be tolerant of the disability.
Reassure the patient.
Give the symptoms a name.
Help the patient regain control.
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Substance-Related Disorders
Regarded on four levels:
Substance use
Substance intoxication
Substance abuse
Substance dependence
Determining the most effective treatment requires
an integrative approach.
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Eating Disorders
Persons may experience severe electrolyte
imbalances.
Two thirds report anxiety, depression, and substance
abuse disorders.
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Eating Disorders
Bulimia nervosa
Consumption of large amounts of food
Compensated by purging techniques
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Eating Disorders
Anorexia nervosa
Weight loss jeopardizes health and lives
Typical patient:
Decreased body weight based on age and height
Intense fear of obesity
Experience amenorrhea
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Somatoform Disorders
Preoccupation with physical health and appearance
Hypochondriasis: Anxiety or fear that the person may have a
serious disease
Conversion disorders: a physical problem results from faking a
physical disorder
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Factitious Disorders
Patient produces or feigns physical or psychological
signs or symptoms.
Symptoms are under voluntary control.
Factitious disorder by proxy: a parent makes a child
sick for attention and pity
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Impulse Control Disorders
Lack of ability to resist a temptation
Examples include:
Intermittent explosive disorder
Kleptomania
Pyromania
Pathologic gambling
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Personality Disorders
Maladaptive patterns of thinking about the
environment and ones self
Cause functional impairment or subjective distress
Be calm and professional.
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Medications for Psychiatric Disorders and
Behavioral Emergencies
Patients may be taking any of several types of
psychotropic drugs.
During your assessment, determine:
Which medications have been prescribed
Whether they are being taken
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Psychiatric Medication Types
Antidepressants
Combat the symptoms of
depressive illness
Alter levels of
neurotransmitters in the
autonomic nervous
system
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Antidepressants (contd)
Fluoxetine: the most commonly prescribed
Side effects are minimal.
Heterocyclic: used for major depression
Side effects are common.
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Antidepressants (contd)
Monoamine oxidase inhibitors: recommended for atypical
major depressive episodes
Potential side effects
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Benzodiazepines
May be prescribed for severe emotional distress
Contraindicated in patients with:
Known hypersensitivity to benzodiazepines
Acute, narrow-angle glaucoma
First-trimester pregnancy
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Antipsychotics
Newer medications have less risk of adverse effects and are
more effective.
Known as atypical antipsychotic (AAP) drugs
Relieve delusions and hallucinations.
Improve symptoms of anxiety and depression.
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Antipsychotics (contd)
May cause metabolic side effects
Cardiovascular effects depend on medication.
May cause an acute dystonic reaction
May cause atropine-like effects
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Amphetamines
CNS and PNS stimulants
Help with ADHD.
Raise systolic and diastolic blood pressure.
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Amphetamines
Psychological effects
depend on:
Dose
Mental state
Personality
Results include:
Alertness
Elevated mood
Increased motor and
speech activities
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Problems Associated with Medication
Noncompliance
Increases the likelihood that a person with mental
illness will commit a violent act
When obtaining medication history, include:
Previously prescribed medications
Missed doses
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Emergency Use of Medications
Emergency use of medications are often required
with violence.
The potential danger is too great not to intervene.
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Emergency Use of Medications
Before administering chemical restraint, complete
your assessment with:
A thorough understanding of the chief complaint
Attention to allergies
Medical and medication history
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Pediatric Behavioral Problems
50% of childhood
mental illnesses will
present by age 14
years.
More likely to have
coexisting problems
Difficult to diagnose
Leah-Anne Thompson/ShutterStock, Inc.
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Pediatric Behavioral Problems
Mental status assessment is similar to that of an
adult.
Exception: Consider developmental level.
Abnormal findings are often related to adjustment
disorders and stress.
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Geriatric Behavioral Problems
Distress and pain may
be caused by:
Exposure to new
experiences
Alterations to routines
Leah-Anne Thompson/ShutterStock, Inc.
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Geriatric Behavioral Problems
Anxiety and depression are too often considered a
normal part of aging.
Ageism: discrimination against older people
Take stock of your own attitudes.
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Summary
Behavioral emergencies can present unique
challenges in patient management. Focus on
reducing the patients stress without exposing
yourself to unnecessary risks.
A behavioral or psychiatric emergency is any
reaction to events that interferes with activities of
daily living.
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Summary
Behavioral emergencies can be a temporary response
to a traumatic event.
Calls for behavioral emergencies have special
medical and legal considerations.
You have limited legal authority to require a patient
to undergo care in the absence of a life-threatening
emergency. Always involve law enforcement
personnel when you are called to assist a patient with
a severe behavior or psychiatric crisis.
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Summary
If a patient poses an immediate threat, leave the area
until law enforcement personnel secure the scene.
Underlying causes of behavioral emergencies fall
into four categories: biologic (organic) causes, causes
resulting from the persons environment, causes
resulting from acute injury or illness, and causes that
are substance related.
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Summary
Psychiatric signs and symptoms occur when mental
health is challenged and psychological mechanisms
or behaviors mobilize to return the persons mental
state to homeostasis.
Assessment of a disturbed patient differs from other
assessment methods in that you are the diagnostic
instrument. Assessment is also part of the treatment.
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Summary
When providing care, be direct, honest, and calm;
have a definitive plan of action; stay with the patient
at all times; and express interest in the patients
story.
When sizing up the scene, pay special attention to
potential dangers and objects that may be used as
potential weapons, hazardous chemicals, etc.
Remove potentially harmful objects.
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Summary
Primary assessment includes identifying yourself,
forming a general impression of the patients
condition and the nature of the problem, assessing
the ABCs, making a decision about transport, and
taking a history via the mental status examination.
Secondary assessment involves looking for signs of
an organic cause of the behavioral emergency.
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Summary
Management is focused on ensuring scene safety and
maintaining awareness of life-threatening
conditions, while treating the patient for any medical
disorders.
Effective communication techniques include
beginning with an open-ended question, showing
that you are listening, allowing silence when
appropriate, avoiding argument, facilitating
communication, and asking questions.
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Summary
Crisis intervention skills include staying calm and
being direct, excluding disruptive people from the
scene, maintaining a nonjudgmental attitude,
developing a plan of action, encouraging motor
activity, and assuming that the patient can hear and
understand everything you say.
Use of chemical or physical restraints is reserved for
times when verbal intervention fails to reduce severe
agitation.
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Summary
Pathophysiologic factors that contribute to
behavioral disturbances include cognitive
impairment, thought disorders, mood disorders,
neurotic disorders, substance-related disorders and
addictive behavior, somatoform disorders, factitious
disorders, impulse control disorders, and personality
disorders.
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Summary
You may encounter patients with psychosis, a
thought disorder characterized by a statue of
delusion in which the person is out of touch with
reality.
You may encounter patients with agitated delirium.
This is impairment of cognitive function that can
present with disorientation, hallucinations, or
delusions, and is characterized by restless and
irregular physical activity.
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Summary
The threat of suicide requires immediate
intervention. Depression is the most significant risk
factor for suicide.
Situations involving violence, abuse, and neglect can
have the potential for escalation and the possibility
of evoking emotional responses in you.
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Summary
Patients with psychiatric emergencies may be taking
any of several types of psychotropic drugs. During
assessment, determine which medications have been
prescribed and whether the patient is actually taking
them.
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Thank You
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DR.

JAYESH PATI DAR

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