Psychiatric Emergencies- Classification and Management

What Are Psychiatric Emergencies?

Psychiatric emergencies are medical emergencies caused due to abnormal, uncontrolled thoughts, moods, and behaviors of sudden distress in patients with mental illness, which can be harmful or life-threatening to the individuals or the surrounding environment, thus requiring immediate management.

Dealing with such emergencies becomes very challenging for the physician, but he must prioritize his staff's safety and safety. Physicians must perform a practical screening assessment to check for any underlying cause of the disease. He must also ensure proper medical care is provided to the patient, even if that has to be done without the patient's consent.

In cases where a patient is violent or can be a threat to the staff, the S.A.F.E.S.T. approach must be followed, which can be elaborated as follows:

• Spacing: It means maintaining a safe distance from a patient, both patient and physician must be at an equal distance from the door, and the physician must avoid touching a violent patient.
• Appearance: A physician must be accompanied by security staff to show strength and have one primary contact person to facilitate communication.
• Focus: The physician must observe keenly and watch the patient's hands; any weapons, if present, or any signs of agitation must be noted.
• Exchange: Communication and exchange of thoughts is the key; thus, physicians must engage the patient with calm and continuous talking, but it must be taken care that no offensive topics are even mentioned during the conversation.
• Stabilization: Whenever necessary, physical restraints, sedation, or chemical restraints should be used.

How Are Psychiatric Emergencies Classified?

Psychiatric emergencies can be classified as major or minor depending on the severity of the disorder created. Minor emergencies are the ones that do not cause a threat to life but have a severe impact on the lives of the patients.

Major Emergencies:

Major emergencies are the ones that cause a threat to the life of the patient or the people around them.

Some of the significant emergencies are as follows:

• Suicidal patients.

• Agitated or violent patients.

• Psychosis leads to threatening behaviors.

• Mania.

• Panic disorder with a panic attack.

• Intoxication state.

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• Anxiety.

Minor Emergencies:

Minor emergencies are the ones that do not cause a threat to life but have a severe impact on the lives of the patients.

Minor emergencies include the following:

• Grief reaction.

• Rape.

• Panic attack.

How Are Psychiatric Emergencies Assessed?

History:

If present, a detailed medical history must be obtained from the patient, surroundings, or guardian.

Examination: Detailed physical and systemic analysis is performed to rule out any wound or head injury.

Mental Status Examination: This is done to formulate a psychiatric diagnosis; assessment is done with the help of the Glasgow coma scale and mini-mental state examination. It helps determine the level of consciousness; any suicidal thoughts, if present, must be assessed.

A mental state examination consists of the following assessments:

Clinical Presentation and Behavior of Subject:

Based on the clinical presentation of the subject following is noted:

• Level of consciousness includes whether the patient is fully conscious, stuporous, comatose, or confused.

• Dress - this is based on observation if the patient is appropriately, shabbily dressed, or overdressed.

• Psychomotor activities are marked as normal, increased, or decreased.

• Cooperativeness - based on the patient's behavior, it is noted is cooperative or uncooperative.

• Rapport - based on the conversation, either Good or poor rapport is developed with the patient.

• Speech - The quantity of speech can be Normal, increased, or decreased.

• Relevance.

• Coherence.

• Continuity.

• Mood - Subjective (what the patient describes) and objective (what the interviewer observes) mood and behavior patterns are studied.

• Perceptions - It should be noted if the patient has hallucinations or illusions.

• Thoughts - The reasoning and thoughts of the patients should be analyzed to determine if they are logical or illogical.

Cognitive Functions:

• Attention and concentration.

• Orientation to Time, Place, and Person.

• Memory: recent and immediate memory is analyzed to determine if it is normal or impaired

• General information and intelligence: if a person has adequate or insufficient information is also observed and noted.

• Judgment: decision-making ability of the person, if it is impacted or impaired, is also determined.

What Are Significant Emergencies?

Major emergencies mainly include suicidal patients and violent subjects.

Suicidality:

Patients with mental disorders sometimes develop suicidal thoughts as a symptom of an underlying mental condition or a side effect of antipsychotic drugs. Thus, such studies must be expelled through psychotherapy or counseling. If unattended, a patient might lose his life or can cause danger to the people around them. Such thoughts must be thoroughly discussed during the regular psychotherapy sessions as any previous attempts or self-destructive behaviors, if noted, can be alarming signs, and such patients must be dealt with caution.

When brought to the emergency room first, such patients must be examined for the method of a suicide attempt. The physical needs of the patients must be taken care of with priority; vitals must be stabilized. The patient's state of consciousness must be examined, and the treatment must follow according to the same.

Once the patient is physically stabilized, his mental state must be reviewed to rule out the cause of the suicidal attempt and any current suicidal thoughts. Depending on the mental health examination, further treatment plans must be formulated. The patient must either be referred to a psychiatrist, or the treatment must continue in the presence or under the guidance of a psychiatrist.

Agitation or Violent Patients:

Patients present with hallucinations and delusions, disorganized thought processes, and unpredictable behaviors. Management includes ruling out any history of drug or alcohol intoxication; a mental state examination is done to determine if a psychotic disorder is present.

Antipsychotic medications are prescribed. In patients with violent behaviors, it is essential to have enough staff support to provide restraint if the patient denies taking injections. Haloperidol, Risperidone, and Trihexyphenidyl injections are administered to calm the patient; even if this does not work and the patient is still violent, Diazepam is administered to settle the patient's behavior. Once this is achieved, further treatment plans can be formulated based on the condition and situation.

How Are Psychiatric Emergencies Managed?

General management of psychiatric emergencies includes:

Safety of the Patient: Such patients must be thoroughly examined and never left unattended or alone; staff must be accompanied in emergency need of restraints.

Nutrition and Hydration: Patients tend to self-neglect and thus are at high risk of dehydration and starvation. Therefore, ensure patients receive adequate hydration and nutrition.

Psycho-Social Support: Inform the family about the illness, to receive full support and cooperation from them.

Medication: Prescribed as and when needed.

Investigation: Thorough examination and investigation is needed.

Notification: Inform the patient's family, a hospital administrator, or other agencies as necessary. Inform the police if a case is medico-legal. Consult a senior colleague if in doubt.

Refer, if necessary, after giving psychological first aid and medical treatment.

Conclusion:

Psychiatric emergencies are medical emergencies in patients with mental health disorders. These emergencies range from minor to significant emergencies where a patient is suicidal and violent. Such patients threaten society and self and thus require immediate medical attention. Treatment aims at stabilizing the patient mentally and physically. The patient is then further referred to the psychiatrist for further therapies and medicines if required.