Psychiatric Emergencies

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SELF-HARM AND ATTEMPTED SUICIDE

Clinical Description

  • An act of self-harm without suicidal intent is deliberately harming oneself, e.g., cutting oneself. A suicide attempt is an act of self- harm with suicidal intent but not resulting in death
  • Both are to be taken very seriously because they are high risk factors for completed suicide in the future
  • Risk of future attempt is raised if:
  • Underlying psychiatric disorder {depression, bipolar affective disorder, schizophrenia/ drug or alcohol misuse or personality disorder)
  • Ongoing suicidal thoughts or plans
  • Regret at having survived the attempt
  • Access to dangerous means e.g., firearms/ agro-chemicals/ medicines
  • Evidence of hopelessness, marked emotional distress
  • Previous self-harm/ suicide attempts
  • Family history of completed suicide
  • Male gender, older age, lack of social support

Clinical Features

SIGNS AND SYMPTOMS

  • Evidence of injuries from or history of actual suicide attempt method e.g., hanging, poisoning, drowning, etc.

Treatment

GENERAL MANAGEMENT

  • Asking about suicidal thoughts in a routine assessment
  • First establish therapeutic rapport
  • Ask how they feel about their life at the moment, how they see the future and if they think life is not worth living?
  • Do they have thoughts about trying to harm them-self or end their life? If yes, have they made any plans. Do they have access to lethal means at home?
  • What has prevented them from acting on these thoughts? What protective factors are in their life? {family/ religious faith/ hope that things will get better)
  • Have they made an attempt to harm them-self end their life in the past? If yes, what happened?
  • If assessing someone presenting with a serious attempt at self-harm, first treat the physical effects of the attempt whilst ensuring that they are in a safe environment e.g. suture any wounds and manage bleeding, monitor appropriately if ingested poisons such as rat poison/fertiliser/ overdose of prescribed or over-the-counter medication
  • All people with a self-harm/ suicide attempt should be referred for assessment by the social worker or mental health team before leaving the health facility
  • If there is current active suicidal ideation with a plan and access to dangerous methods, the person should be referred for assessment for admission by the psychiatry team urgently. If patient is unwilling or uncooperative, involuntary admission and subsequent referral for psychiatric assessment may be done under the Mental Health Act (Temporary Treatment Order).
  • If suicidal thoughts are present but there is no plan and protective factors are in place, treat any underlying psychiatric disorder, give supportive counselling, with patient’s consent alert guardians or relatives, eliminate potentially lethal means in home environment and provide pathway to care e.g., contacts for subsequent suicidal ideation. Monitor the suicidal thoughts at follow up visits. If the suicidal ideation does not improve, refer for assessment by the psychiatry team

 

ACUTELY DISTURBED OR VIOLENT BEHAVIOR

Clinical Description

  • Most people with psychiatric disorders are never aggressive or violent
  • However, some factors do make it more likely that some people may become aggressive when unwell e.g., active psychotic symptoms, agitation and over activity, auditory hallucination, confusion and disorientation, alcohol, or drug use)
  • Factors associated with violence or aggression
  • Feeling threatened
  • Young male
  • Previous or recent history of aggression
  • Drug or alcohol use
  • Increased impulsivity – e.g., delirium, brain injury, learning disability, dementia
  • Psychiatric disorders - e.g., schizophrenia with current active psychotic symptoms especially command hallucination or paranoid persecutory delusion, mania

Clinical Features

SIGNS AND SYMPTOMS

  • Making verbal threats or shouting
  • Agitation or irritability
  • Suspiciousness/ anxious look
  • Pacing up and down
  • Actual physical aggression towards people or property

INVESTIGATIONS

  • Assess for bio-psychosocial causes of the acute disturbed or violent behaviour

Treatment

  • The aim is to alleviate suffering and to prevent harm/ injury to the patient and the health care staff
  • Also, to allow investigation and management of the underlying cause of the aggression e.g., delirium, psychosis, mania

General Measures

  • First ensure your own safety – Avoid interviewing patients in isolated places (avoid being trapped in a corner; have other staff or guardians with you), terminate interviews if patients become increasingly agitated and move towards a safer place
  • De-escalation of the situation:
    • Give clear, brief, assertive instructions
    • Explain your purpose or intention
    • Negotiate options and try to understand the reason for their distress
    • Avoid verbal and non-verbal threats
  • If de-escalation attempts fail, prescribe pharmacological management -Offer oral sedation initially and proceed to rapid parenteral tranquilization if refused
  • Avoid use of diazepam in lactating women
  • Have at least four additional people to handle patient if rapid tranquilization is needed
  • If patient comes while tied do not immediately remove physical restraints until safe to do so

Steps of Rapid Tranquilization (RT)

Step Intervention Dosages of Medication Other/ Adjuvant treatment

  • De-escalation
  • Offer oral treatment Repeat this up to 2 more time at 30-minute intervals if person remains agitated Haloperidol 2.5- 5mg or Chlorpromazine 100-200mg with or without oral Diazepam 5-20mg or lorazepam 1-4 mg or Promethazine 50mg.
  • Consider IM treatment if the person doesn't accept oral medication or is not effective.
    • Haloperidol 5mg or Chlorpromazine 50-100mg or Lorazepam 1-4mg
    • Lorazepam 1-4mg IM, Promethazine 50mg IM is an alternative in benzodiazepine- tolerant patients (people with alcohol dependence)

Note: Diazepam should NOT be given IM

  • Consider IV treatment using large vein Diazepam 5-10mg slow push over at least 5min.
  • repeat after 5-10 min if insufficient effect {up to three times) 

Note: if giving IV Diazepam, patient should be continuously monitored through vital signs recording every 15 minutes

  • Seek expert 

General monitoring after RT

  • Pulse
  • BP
  • Respiratory rate
  • Temp
  • Oxygen saturation should be monitored every 15 minutes for the first hours and then every 30 minutes until the patient is awake and alert
  • Full physical examination including vital signs to determine if any physical cause for the aggression e.g., delirium, drug or alcohol withdrawal