Emergency Psychiatry

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Emergency Psychiatry

• By
• Dr. Narong Maneeton

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Patient Assesment

• Hx. ??????? ???? ?????? ??????????
• PE, MSE, Lab

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?????????????????????

• ?????????????????????????????????????
• ????????? Countertransference Reaction
• ??????????????????????????????????????
  ????????????????

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???????????????????????

• Organic Sign
• -Acute Onset
• -First Episode
• -First in Old Age
• -Physical illness or Injury

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-Drug use , Abuse-Hallucination-Neurological
Deficit-Speech, Movement Ab.-??????????????????
-Catatonic Feature
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?????????????????????????????-Suicide
Violence-Hyperventilation Syndrome-Panic
Disorder-Posttraumatic stress disorder
(PTSD)-Physical Sexual abuse-Delirium Acute
Psychoses-Substance use disorder
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Intervention in Psychiatric Emergency

• Physical Restraint
• Pharmacotherapy
• Hospitalization
• Management of Medical Problem
• Crisis Intervention

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Crisis Intervention

• Supportive Psychotherapy
• Environmental Manipulation
• Dealing with Supporting System

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Suicide
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Suicidal Risk Factors

• Major Depressive Disorder Endogenous
• Alcohol Dependence gt 50 ????
• Drug Addiction 10 ????
• Personality Disorders BPD
• Schizophrenia

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• Organic Psychosis
• Previous Attempted suicide
• Fm Hx of Suicide
• Poor Physical Health
• Recently Loss
• Parent death in Childhood
• Aniversary

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• Sex male gt female
• Age
• Geography
• Marital Status divorcedgtsinglegtwidowedgtmarried
• Socioeconomic extremely status

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SAD PERSONS Scale

• Sex
• Age
• Depression
• Previous attempted
• Ethanol abuse

• RationalThink. Loss
• Social Supp. Deficit
• Organized plan
• No spouse
• Sickness

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SAD PERSONS Scale

• 0-2 Little Risk
• 3-4Follow Closely
• 5-6Strongly considered psychiatric
  hospitalization
• 7-10Very high risk, Committed Hospitalization

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Management

• Suicidal evaluation, ??????????????????????,??????
  ??????????????
• Planning or Impulsiveness
• Alcohol Intoxication ?
• Schizophrenia high risk

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• Personality dis Empathy
• Treat the Underlying Psychiatric abnormality
• High Risk Hospitalization

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Psychopharmacotherapy

• Anxiolytic Drugs
• Antidepressants

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Violence
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Diagnosed asso with violent behavior

• Psychotic disorders
• Schizophrenia
• Delusional disorders
• Postpartum psychoses
• etc.

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• Organic mental disorders
• Delirium
• Drug intoxication
• Personality disorders
• Antisocial
• Paran
• oid, other c transient psychosis

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• Situational Problem
• Domestic Quarrels (Spouse abuse)
• Child abuse
• Homosexaul panic
• Brain disorders
• Seizure, MR, Minimal brain dysfunction
• Structural defect ( trauma, encephalitis)
• Dissociative

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Management and Evaluation

• Protection for Others
• -??? pt ??? violent ???????????????????????
• -approach ?????????????????????
• -re-assure ?????????????, ??? reality testing
• -medication

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• -inform to Restraint if cannot control yourself
• -Show Force
• -Monitor vital sign

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Impending Violence

• Recently violent behavior
• Verbal and Physical threatening
• Armed or sharp objects
• Progressive Psychomotor Agitation
• Alcohol or Drug intoxication

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• Paranoid
• Voice Commanding
• Brain disease
• Catatonic excitement
• Mania
• Agitated Depression
• Personality dis Impulsive

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Management

• Protect yourself
• -???? Hx ?????????
• -?????????, ?????? ?
• -?????????????????? pt ??????? violent ???????
• -Environment
• -Rapport

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• Evaluate sign of impending violence
• ???????????????????????
• Restraint pt ??????????????
• Dx., DDx., Tx.Plan
• Hospitalization
• ??????????????????????????????????
• ????????????????????????

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Psychopharmacotherapy

• Antipsychotics Haloperidol IM Oral 2-10 mg q
  2-4 hrs
• Benzodiazepine
• B-Blocker

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Hyperventilation Syndrome
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Clinical Feature

• Dizziness, Light headness, Fainting, Paresthesia,
  Carpopedal spasm

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Differential Diagnosis

• Siezure, Epilepsy
• Hypoglycemia
• Vagovagal attack
• Myocardial Infarction
• Asthma

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• Porphyria
• Pheochromocytoma
• Meniers disease
• Conversion

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Interview and Management

• ?????????????????????? ???????????????????????????
  ???????????????
• ??????????????????????????????????????????????????
  ????
• ????????????????
• ??????????????????????????????
• Medication Benzodiazepine IM Oral

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Panic Disorder
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Clinical Feature

• Palpitation, Shortness of breathing, Sweating,
  Checking, Dizziness, Fear of dying, Fear of mad
  or loss of control
• Onset Early Adult
• Followed by Agoraphobia

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Evaluation and Management

• Rule out the Medical disease
• Hx. Of Substance use
• Other psychiatr dis depression, OCD,PTSD
• Medication Benz. alprazolam, clonazepam,
  lorazepam
• Antidepressant

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PostTraumatic Stress Disorder
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Clinical Feature

• Exposed to traumatic event
• Traumatic event persistently reexperience
• Persistent avoidance of stimuli ass c trauma
• Persistent symptoms of increased arousal

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Evaluation and Management

• Clinical Dx. , Evaluation of intox withdraw
• PE, NE, Lab
• ????? Trust ?????????? ??????????(
  ??????????????????)
• ????????? support, suggestion, reassure

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• Group Psychotherapy
• Medication
• -Antidepressant
• -Benzodiazepine
• -Others B-blocker, Lithium, Cloidine,
  Carbamazepine

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Physical Sexual Abuse
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Child Abuse

• Physical and Psychological in child below
• 18 Yrs
• Usually by Parent, Caretaker, Relatives

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Clinical Feature

• Physical Abuse Bruise, Fracture, Dislocation,
  Burn, Tearing wound, Neurological deficit,
  Abdominal trauma, Food or Water Starvation
• Battered child syndrome
• Munchausen syndrome by proxy

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• Sexual Abuse
• -????????? ???????
• -Irritation, FB of Anus or Vagina
• -Preoccupy in masturbation
• - STD, HIV,Pregnancy
• -PTSD, Somatic complaint, Regressive Beh.
  Depression, Suicide

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• Emotional Abuse
• -Aggression or Maltreatment by caretaker
• -May be unwanted child
• - Increased in MR parent
• -Failure to thrive
• -Hypokinesis, Apathy, Distress, Unhappy,
  Malnutrition, Fear

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Evaluation and Management

• ????? ????????????????????????????????
• 1/3 pt ?????????????????????? 5 ???
  ??????????????????
• pt gt 5 ??? guilty, fear, betrayed ????????????
• ??? Hx ??????????? ?.?. ???? ???????????

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• ??????????? ????????????? , hospitalization
• ????????????? ?????????????? ?????????????????????
  ??? ???????????????????
• Sexual abuse ??? culture secretion ??????
  ???????? ????????
• ????????????????? ????????
• ??????????????????????????????????

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• ??????? ????????????? ??????????????? ????????
• Group Psychotherapy
• ??????????????? Psychosocial

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Elderly Abuse

• Physical manifestation
• -?????? ????? pressure sore, fecal impaction,
  dermatitide, ??? bruise, burn, wound, vaginal or
  anal injury

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• Psychological manaifestation
• -Confusion, Psychomotor retardation or
  agitation, Depression, Suicidal ideation or
  attempt, Anger, Apathy, Excessive sleep or
  Insomnia

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Evaluation and Management

• ???????????????????????????
• ??????????????? ??????????? ???????
• ?????????????????????????
• ????????????????????????????? ?
• ??????????????????????????????????????????????????
  ????????

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• ?????????????????????????????????????

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Spouse Abuse

• Domestic Violence
• ????? Multiple Injury

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Evaluation and Management

• Hospitalization (??????????????)
• ???????????????????? ?
• ?????????????????????????????????
• ???????????????????????
• ????????????????????????????? Benzodiazepine

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Substance Use Disorders
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Alcohol Withdrawal

• Hx. ????????????? ???????? ???????????????
• Coarse tremor, Nausea, Weakness, Autonomic
  hyperactivity, Anxiety, Irritable,Transient
  illusion or hallucination, Insomnia, Numbness,
  Paresthesia

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Treatment

• Benzodiazepine 5-10 mg q 4-6 hr.
• Vitamin Suppl.
• Supportive Tx. Hypoglycemia, Electrolyte
  imbalance

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Alcohol Withdrawal Seizure

• 90 occur in 48 hr.
• Generalized Tonic-Clonic
• Tx. DZP 2-10 mg IV

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Alcohol Withdrawal Delirium

• Onset 2-7 ???
• Disoreintation, Agitation, Hallucination
• Autonomic hyperactivity, Tremor, Dilated pupil
• Mortality rate 20

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Management

• DZP 10-20 mg q 2-4 hr , 3-5 ???
• Vatamin Suppl
• Supportive Tx
• ????????????????? delirium

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Amphetamine Intoxication

• Mod Intox. Euphoria, Hi self-esteem,
  Grandiosity, Suspiciousness, Miosis, Tachycardia,
  Nausea, Perspiration, anxious
• Severe Intox. Hypervigilant, Paranoid,
  Psychomotor agitation, Delirium, Arrythmia,
  Convulsion, Coma , Death

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Treatment

• Urine for Amphetamine
• Reassure the Patient
• Precaution HT, Hyperpyrexia, Siezure, Violence,
  Suicide
• Anxiety or Agitation BZD
• Acidified Urine

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Amphetamine Delirium

• Agitated Confusion
• Hallucination, Delusion,
• Hyper Autonomic Activity

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Treatment

• Agitation or Psychosis Haloperidol 2-10 mg q 30
  min
• Precaution Violence , Psychosis
• Acidified Urine

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Amphetamine Psychosis

• Hallucination
• Delusion
• Normal Sensorium and Cognition

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Treatment

• Haloperidol 2-10 IM q 30 min
• Acidified Urine
• Urine for Amphetamine

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Opioid Intoxication Overdose

• Morphine
• Heroin
• Methadone
• Codein
• Other

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Clinical Feature

• Objective Sign CNS , GI motility ????, Resp ,
  Analgesia, Nausea, Slurred speech, Hypotension,
  Bradycardia, Pupillary constriction , Siezure
• Subjective Sign Euphoria, Anxious , Dysphoric ,
  Downsiness, Conc. Memory ????

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Overdose

• Pin Point Pupil
• Resp depression
• CNS depression

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Treatment

• ICU, V/S
• Naloxone 0.8 mg , 1.6 mg , 3.2 mg IV.
• ???????????? Naloxone 0.4 mg q hr IV
• ?????? Naloxone ????? Severe Withdrawal

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Opioid Withdrawal

• ?????????????????? , Craving, ??? , ??????,
  Insomnia , Muscle pain, Dilated pupil,
  Piloerection, Tremor, Restless, N/V, Diarrhea ,
  Hyperautonomic Activity,

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Treatment

• Objective Sign 10 mg methadone 5-10 mg 4-6 hr
  ????????? 3-4 ???
• Clonidine ??????? N/V, Diarrhea,

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Delirium
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Acute Psychoses
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Clinical Feature

• Inpairment of Overal Function
• Abnormal Content of Thought
• Illogical Form of Thought
• Distorted Perception
• Changed Affect

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• Impaired Sense of Self
• Alteration Volition
• Impaired Interpersonal Function
• Change in Psychomotor Behavior
• Normal Sensorium

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Treatment

• Hospitalization
• Psychopharmacotherapy
• Psychosocial Tx.