Psychiatric emergencies

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Psychiatric emergencies
Definition: Psychiatric emergency is a disturbance in thought, mood and/or action which causes sudden distress to the individual (or to significant others) and/ or sudden disability, thus requiring immediate management.
Types
1.      Suicide
2.      Stupor &Catatonic syndrome
3.      Excited and violent behaviour
4.      Aggressive behaviour
5.      Anger
6.      Other psychiatric emergencies
Suicide

Meaning: It is a human act of self intentioned and self inflicted death.
Epidemiology:
·         Highest prevalence of adolescence suicide is in South East Asia and Europe (Mac.Louglin A B)
·         Highest suicide is seen in India.
·         One person commits suicide in every 40 seconds
·         According to WHO report more than 2 lakh people committed suicide in the year 2012.
·         Suicidal death rates are higher in males than females.
·          Most common methods are poisoning and hanging.
Etiology
Psychiatric Disorders
·         Major depression
·         Schizophrenia
·         Drug or alcohol
·         Dementia
·         Delirium
·         Personality disorder
Physical Disorders
·         Cancer
·         AIDS
·         pain
Psychosocial factors
·         Loss of loved one
·         Isolation
·         Financial problems
·         Marital problems
Risk factors for suicides
·         Age
o   Males above 40 years
o   Females above 55 years

·         Sex
o   Men have more completed suicide
o   Women have higher rate of attempted suicide
o   Single individuals
o   History of previous suicidal attempts.
Management
·         Identify the early warning signs of suicides like
o   Suicidal threat
o   Making a will
o   Closing bank accounts
o   Giving away possessions
o   Writing suicidal notes
o   Being happy after a period of depression
·         Consider all the suicidal threat/gestures as serious and notify the mental health professional
·         Do a risk assessment and take precautions
·         Remove all sharp objects, ropes and any potentially hazardous objects from the reach of the patient.
·         Avoid patient access to drug tray.
·         Keep the patient under close observation by assigning a room which is visible from nurse’s station.
·         Don’t allow the patient to lock the room or doors of toilet.
·         Patient should not be left alone.
·         Have vigilant observation during morning hours.
·         Encourage to express his/her feelings
·         Sedation if severe suicidal tendencies exist based on Doctor’s prescription.
·         Counselling and guidance in helping to resolve the problems faced by the patient.
·         Maintain a suicidal pact after discussing with the patient.
·         Encourage in discussing with the staff nurse if any suicidal thoughts are coming.
·         Promote self esteem of the patient by identifying strength and weaknesses and promoting the positive qualities.
·         ECT can be effective if the patient is diagnosed to have major depression and associated suicidal risk.

Management of attempted suicide
·      Monitor the vital signs.
·      Stabilize the patient by immediate management
·      Refer to counselling services
·      Closely monitor for repeated attempts

Management in suicidal death
·         Inform the hospital authority and police immediately
·         After police arrives remove the body from the public area
·         Involve other patients in diversional activities
·         Record the incidence
·         Transfer body to mortuary
·         Hand over patient properties to relatives.
·         Observe all the other patients carefully for any change in behaviour and notify the mental health professional.


Violence
Etiology
      Organic psychiatric disorders
      Non-Organic psychiatric disorder
      Mania
      Depression
      Drug and alcohol dependence
      Epilepsy
      Acute stress reaction
      Neurotic disorders
      Impulsive violent behaviour
      Reactive psychosis
Nursing Management
      Talk to the patient
      Collect detailed history
      Physical examination
      Have less furniture in room
      Reduce the environmental stimuli
      Remove sharp objects
      Stay with the patient
      Redirect violent behaviour
      Encourage expression of feelings
      If unable to manage restraint can be used
      Protection of self


Stupor
Etiology
      Neurological disorders
      Metabolic disorders
      Drugs and poisoning
      Psychiatric disorders
Management
      Ensure patent airway
      Collect history
      Draw blood for investigations
      50ml of 50% dextrose in case of hypoglycemia
      If stupor is drug induced
In case of Morphine poisoning, Naloxone 0.4mg IV
In case of Anticholinergic poisoning, Physostigmine 1-2mg IV
In case of Wernicke’s encephalopathy, Thiamin 100mg IV
Other psychiatric emergencies
      Delirium tremens
      Hysterical attacks
      Drug induced extra pyramidal syndrome
      Drug toxicity




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Psychiatric emergencies
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