1. PSYCHIATRIC EMERGENCIES Dr. Rabie Hawari Consultant Psychiatrist Clinical Assistant Professor

2. SUICIDE A willful self-inflicted life- threatening act which has resulted in DEATH.

3. ATTEMPTED SUICIDE OR DELIBERATE SELF-HARM OR PARASUICIDE * An act of self-damage carried out with destructive intent. * An attempt without the will to finish one ’ s life.

4. SUICIDE RISK FACTORS Previous Hx. Of Affective Disorder = Depression. Hx. Of Alcoholism & Drug Abuse. Sever physical illness in the elderly = Ca. Recent bereavement, separation, loss. Family Hx. Of Affective Illness. Previous Suicidal Attempts. Personality problems i.e. Cyclothymic, Antisocial. Poor social support, living alone, unemployed, single. Other symptoms: Agitation, Insomnia, Guilt, Male, Older age, Divorced, Suicidal threats.

5. METHODS USED examples; Self-poisoning:- coal gas poisoning. Drugs- tranquilizer, Salicylates, Antidepressant. Violent means:- hanging, firearm, cutting, etc.

6. MANAGEMENT Active treatment of the physical condition. Detect high risk group. Close observation 1=1. Treatment of any Psy. Illness. Social & Psychological support. Admission to Psych. Unite if the immediate crisis passed & the Pt. suffers from Psych. Illness & of high risk group. If the situation is not one of OD. Pt. may need sedation e.g. Nitrazepam 10-15mg. CPZ. 100-200mg.

7. DELIBERATE SELF- HARM An attempt without the will to finish one ’ s life. Causes:- personality Diso. e.g. Psychopath or Hysterics - alcoholism. - reactive ( neurotic ) depression. - situational crisis.

8. Correlating Factors :- - not well planned act. - female, young, unemployed, single. - previous attempts, psychosocial stresses. - broken home background

9. Management of DSH :- - assessment of physical seriousness - admission. - assessment for Suicide Risk Factor. - treatment of any Psychiatric Illness. - psychotherapy.

10. SIDE-EFFECT OF PSYCHOTROPIC DRUGS A. Neuroleptic Malignant Synd. (NMS):- Is an acute or subacute Hyperthermic reaction to neuroleptic therapy with a mortality of 20%. Features:- Hi. Fever … Extrapyramidal rigidity … Altered consciousness … Raised Creatine Phosphokinase (cpk)= 15000iu/l.

11. Management of NMS:- -Stop all neuroleptic drugs. Vigorous cooling is needed. Oxygen, i.v. hydration, prevention of renal failure, bicarbonate for acidosis. Dantrolene sodium 200mg (slow),1.25-10/kg. i.v.(fast) for 12-48hr. after control of fever. or Bromocriptine p.o. or i.v.(^ 60 mg/day)  rigidity.

12. Cont. S/E. of Psych. Drugs; B. Acute Dystonia :- Involuntary contraction of skeletal muscles in head & neck  Oculogyric Crisis Management:- - I.M. Procyclidine (kemedrine) 5-15mg. - Diazepam 10mg i.v.

13. Cont. S/E. of Psych. Drugs; C. Akathisia :- Minor restlessness & tension. pt. unable to keep from fidgeting, subjective feel of restlessness. Management:- Anti-parkinsonian drug.

14. S/E. of Psych. Druges D. Pseudoparkinsonism :- This mimic idiopathic Parkinsonism:- - stiffening of the limbs, - lack of facial expression, - tremor of hands & head at rest, - sialorrhoea & seborrhoea.

15. Management of Ps-Parkinsonism:- Stop the drug temporarily or sharply reduce the dose. Use Anti-Parkinsonian Drugs:- = Benzhexol (Artane) 2- 4mg.t.i.d. = Procyclidine ( Kemedrine) 5-15tid. = Orphenadrine( Disipal ) 50 -100mg tid.

16. MANAGEMENT OF VIOLENT PATIENT Usually the majority of Psychiatric patients are not Hostile, Dangerous or aggressive, BUT occasionally Psychiatric Illness presented in Aggressive Behavior

17. Examples of Violent Pts.:- 1. Psychopathic Personality Disorder. 2. Hypomania or mania >>> may be angry & hostile if they are obstructed 3. Schizophrenia >> due to Delusional beliefs or in response to auditory Hallucination. Catatonic type >> outbursts of over activity &/or aggressive behavior.

18. Cont. examples of violent Pts. 4. Alcohol & Drugs:- Alcohol >> reduce self-control>> aggression C.N.S. stimulants ( amphetamine ) >> over activity & over stimulation >>> Aggression. Heroin addicts during Withdrawal phase.

19. Cont. Examples of Violent Pts.:- 5. Acute Confusional State >> clouding of consciousness >>> diminished comprehension, anxiety, perplexity, delusion of persecution >>>> Aggression. 6. Epilepsy:- in the post-epileptic confusional state.

20. Cont. Examples of Violent Pts. 7. Dementia:- cerebral damage >>>> decreased control >> aggression Catastrophic Reaction:- when facing difficult tasks they become restless, disturbed, angry, aggressive, throw things & attack people mostly at night.

21. MANAGEMENT OF VIOLENT PT. - Doctors, Nurses, relatives should treat such pt. with understanding & gentleness as possible. - Adequate security. - Raise of alarm. - Availability of more staff. - clear prevention policy to all. - Remain calm, non-critical.

22. Cont. Manage. Of Violent pt. - Use minimum force with adequate numbers of staff. - Talk pt. down. - Physical restrain. - Medication:- * typical :- Major Tranquilizer. Chlorpromazine 50-100mg im. Droperidol 10-20mg im or iv.. Clopixol Aquaphase 50-100mg im * atypical:- risperidone 4mg Or zyprexia 10mg im.

23. Cont. manage. Of violent pt. Medication cont.:- * Benzodizepine:- Diazepam 5-10mg iv. In epilepsy, withdrawal of alcohol or barbiturates. ( may disinhibit violence.)

24. DELIRIUM TREMENS D.T. :- arises 2-4 days after sudden withdrawal or stopping of alcohol features:- hallucinate, delusion, confused, inattentive, agitated, restless, insomnia, tearful, autonomic overactivity, coma, death. management:- Benzodiazepine p.o or iv. to reduce WD symptoms in large doses & taper off in a wk. + large doses of vit. B. and correct fluid & electrolyte.

25. ACUTE CONFUSIONAL STATE. Characterized by :- * clouding of consciousness, * disorientation, * visional hallucination, * perplexity, disturbed behavior. Management:- - admission, - treat underlying cause ( infection) - explain to pt. investigations, treatment, in clear voice & well lit room, reduce staff - chlorpromazine or haloperidol for control.

26. ACUTE ATTACKS OF ANIETY OR PANIC Features:- 1. experiences of intense terror, 2. sweating & drying of mouth, 3. feeling of distress in chest & pericardial pains, 4. transmitted to members of family, 5. often at w/ends or middle of the night. Management:- - reassurance, - Benzodiazepine. ( diazepam 5-10mg po/iv)

27. OTHERS:- STUPOR:- cause Akinesia, Immobility, Muteness with preserved consciousness. It is life threatening b/c of dehydration. causes :- - functional  depression, catatonia, hysterical, mania. - organic  20%, Brain Stem Lesions, lesions around 3 rd.Ventrical. management:- - Abreaction ( Na. amytal or Diazepam) - ECT. - And treat the underlying.

28. OTHERS:- BRIEF REACTIVE PSYCHOSIS :- emotional turmoil, extreme liability, impaired reality testing after obvious psychosocial stress. Management:- admit, antipsychotic, resolves spontaneously.

29. OTHERS:- HYPERVENTILATION:- anxiety, terror, clouded conscious, giddiness, faintness, blurring vision. Management:- breathe into bag  shift alkalosis, education, antianxiety agent.