Part II Part II
Chapter 7 Chapter 7
Principles and Management of Psychiatric Emergencies
DEFinitiOn
A psychiatric emergency is any disturbance in thoughts, feelings, or actions for which immediate therapeutic intervention is necessary.
Major emergencies:
suicidal patients; agitated and aggressive patients Minor emergencies:
grief reaction; rape; disaster; panic attack Medical emergencies:
delirium; neuroleptic malignant syndrome; serotonin syndrome, monoamine oxidase inhibitors (MAOI)/tyramine reactions; overdosages of common psychiatric medications; overdosages and withdrawal from addicting substances
EtiOLOgy/BacKgrOUnD
Approximately 29% to 30% of psychiatric emergency patients are suicidal,
approximately 10% are violent, and approximately 40% require hospitalization.
Psychiatric emergencies peak between 6 p.m. and 10 p.m. when family members
are home together and confl icts arise; substance use increases and aggravates disruptive behavior. Family physicians, pastors, counselors, and other resources are diffi cult to reach.
Patients present with severe changes in mood, thoughts, or behavior; those expe-
riencing severe drug adverse effects need urgent psychiatric assessment and treatment.
Psychiatric emergencies often erupt suddenly. A person may curse, hit, throw
objects, or brandish a weapon.
Patients may neglect self-care, stop eating, exhibit confusion, wander into traffi c, or
appear unclothed in public.
Because psychiatric emergencies can be concomitant with medical illnesses, it is
imperative that the emergency department (ED) physician establish whether the patient’s symptoms are caused or exacerbated by a medical disease, such as infec- tion, metabolic abnormality, seizure, or diabetic crisis.
Emergency psychiatry includes specialized problems such as substance abuse, child
abuse, and spousal abuse, as well as violence (suicide, homicide, and rape) and
social issues (homelessness, aging, and competence). People with mental illness often lack a primary care physician and seek health care in crisis. Often uninsured, they have been denied coverage due to medical illness.
inciDEncE
Psychiatric emergencies from acute psychotic disturbances, manic episodes, major
depression, bipolar disorder, and substance abuse are responsible for approximately 6% of all ED admissions in the United States.
In bipolar mania, agitation occurs with a frequency of approximately 90%; in schizo-
phrenia, agitation accounts for approximately 20% of psychiatric emergency visits.
Drug and alcohol intoxication or withdrawal is the most common diagnosis in
combative patients.
In 2006, there were 1,742,887 drug-related ED visits nationwide.
Thirty-one percent involved illicit drugs only.
Twenty-eight percent involved misuse or abuse of pharmaceuticals (i.e.,
prescription or over-the-counter medications, dietary supplements) only.
Thirteen percent involved illicit drugs with alcohol.
sUiciDaL statE
Suicidal ideation and behavior are the most serious and common psychiatric emer- gencies.
Each year approximately 30,000 people in the United States and 1 million world-
wide commit suicide; 650,000 receive emergency treatment after attempting sui- cide. It is the tenth leading cause of death worldwide.
Suicide is highly prevalent in the adolescent population. Confounding comorbidi-
ties include depression, antisocial behavior, and alcohol abuse.
A history of suicide attempts increases the odds of completing suicide more than
any other risk factor.
Most people who commit suicide reportedly never made a prior attempt and have
never seen a mental health professional.
People who attempt suicide more than once and later complete the act tend to be
more anxious and socially withdrawn.
In the United States, the majority of suicides are completed with firearms, followed
by hanging among men and poisoning among women.
Risk factors for suicide include the following:
Psychiatric illnesses
More than 90% of persons who attempt suicide have a major psychiatric
disorder.
The most common mental health disorders leading to suicide include major
depression, substance abuse, schizophrenia, and severe personality disorders.
Impulsivity and hopelessness
History of previous suicide attempts
Age, sex, and race
Risk increases with age.
Young adults attempt suicide more frequently, but successfully complete less
frequently than the elderly.
Psychiatric EmErgEnciEs 71
Elderly (above 85 years) White males have the highest suicide rate.
Suicide rates have traditionally been higher among Whites compared with
Blacks. The incidence of suicide attempts among young Blacks is rising.
Marital status
Whatever the family structure, living alone increases risk of suicide.
Occupation
Unemployed and unskilled persons are at higher risk.
Health status
Risk increases with physical illness such as chronic or terminal illness, chronic
pain, and recent surgery.
ViOLEnt BEhaViOr
Certain features can serve as warning signs that a patient may be escalating toward physically violent behavior. The following list is not exhaustive:
Facial expressions are tense and angry
Increased or prolonged restlessness, body tension, pacing
General overarousal of body systems (increased breathing and heart rate, muscle
twitching, dilating pupils)
Increased volume of speech, erratic movements
Prolonged eye contact
Discontentment, refusal to communicate, withdrawal, fear, irritation
Thought processes unclear, poor concentration
Delusions or hallucinations with violent content
Verbal threats or gestures
Reporting anger or violent feelings
Blocking escape routes
agitatiOn anD aggrEssiOn
Aggressive, violent patients are often psychotic and diagnosed with schizophrenia,
delusional disorder, delirium, acute mania, and dementia, but these behaviors can also result from intoxication with alcohol or other substances of abuse, such as cocaine, phencyclidine (PCP), and amphetamines.
Medical disorders associated with violent behavior include (not all inclusive) the
following:
Neurological illnesses
—seizure disorders, hepatic encephalopathy, cerebral infarcts, encephalitis, Wilson’s disease, Parkinson’s disease, intracranial bleeds Endocrinopathies—
hypothyroidism, Cushing’s syndrome, thyrotoxicosis, diabetic crisis
Metabolic disorders
—hypoglycemia, hypoxia, electrolyte imbalance Infections
—AIDS, syphilis, tuberculosis Vitamin deficiencies
—folic acid, pyridoxine, vitamin B12 Temperature
disturbances—hypothermia, hyperthermia, vitamin D Poisoning
Behavioral signs of agitation include excessive motor restlessness, irritability, jitteri-
ness, and purposeless and repetitive motor or verbal activity.
Precautions should be taken to modify the environment to maximize safety.
Ensure that patient is physically comfortable and in an environment with low
levels of stimulation.
Minimize waiting time.
Communicate in a safe, respectful attitude.
Remove all dangerous objects.
Aggressive behavior is usually managed with some combination of seclusion,
physical restraints, monitoring with constant observation by a sitter, and drug therapy.
Seclusion offers a decrease in external stimuli that may be enough to reduce
aggressiveness.
Restraints may be needed to obtain a thorough assessment.
Drug therapy such as tranquilization should target control of specific symptoms.
Rapid calming or tranquilization of a patient is achieved with benzodiazepine or an
antipsychotic given intramuscularly (IM) or intravenously (IV).
Typical or atypical antipsychotic may be used.
Benzodiazepines act more quickly but often have erratic IM absorption.
A combination of both drugs can be very effective.
If oral medications are appropriate, orally disintegrating or liquid formulations are
available for haloperidol, risperidone, olanzapine, and aripiprazole.
DrUg thEraPy FOr agitatiOn in Psychiatric EmErgEnciEs
It is better for a patient to take medication voluntarily and orally before the behav-
ior escalates than to be involuntarily medicated after a crisis.
The decision on which medication to use is often based on the underlying diag-
nosis. If the patient is known to be schizophrenic or bipolar and most likely is in a psychotic or manic state, then an antipsychotic should be used. If the diagnosis is unclear or the result of intoxication with drugs or alcohol, then lorazepam, a benzo- diazepine, is most often administered.
Medications discussed are those that have injectable dosage forms. There are other
antipsychotics in liquids or disintegrating tablet forms that would work as well in the appropriate patient.
DiagnOstic WOrKUP
Mental status examination to rule out contributing mental illness to psychiatric
emergency
Physical examination to rule out physical explanation for psychiatric emergency
Laboratory evaluation:
White blood cell count (WBC)
—to look for infectious contribution
Serum electrolytes, creatinine, blood urea nitrogen (BUN)—
to rule out electrolyte
abnormalities, such as hyponatremia, dehydration, and renal insufficiency, which can contribute to agitation
Liver function tests—
hepatic encephalopathy and hyperammonemia can present with agitation and aggression
Toxicological analysis of serum and urine—
substance abuse contribution to emergency
Neuroimaging (CT/MRI)—
rule out stroke, tumor
EEG—
if seizure disorder is suspected
Psychiatric EmErgEnciEs 73
mEDicaL/LEgaL PitFaLLs
Involuntary administration of psychotropic medications is allowed in emergencies
that are considered life threatening. Wide variations exist in the legal definition of
“life-threatening” and in the practice of administering involuntary medication.
Timely documentation of the need for restraint and involuntary medication is
essential.
Informed consent: The most important element of informed consent is the assess-
ment of decisional capacity, for example, through the use of the Mini-Mental State Examination.
If the patient is suffering from either an organic or a functional acute change in
mental status and is a danger to self or others, then the patient should undergo emergency medical evaluation. If the patient will not voluntarily submit to this evaluation, then a request for an emergency medical evaluation from a judge, jus- tice of the peace, or police officer is obtained.
Chemical or physical restraints may be necessary in the combative patient.
Chemical restraints typically include benzodiazepines and/or antipsychotics.
Physical restraints are a last resort and are used mostly by security with close observation.
Protocols for restraints will vary by community.
Physical restraints should be used in the least restrictive manner and for the least
amount of time possible.