psychiatry emergency ppt

D R . J AY E S H PAT I D A R

Psychiatric

Emergencies

National EMS Education Standard Competencies

Psychiatric

Recognition of

Behaviors that pose a risk to the EMS provider, patient, or others

Assessment and management of

Basic principles of the mental health system

Suicidal/risk

4/25/2014

2

www.drjayeshpatidar.blogspot.com


Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of

Acute psychosis

Agitated delirium

Cognitive disorders

Thought disorders

Mood disorders

Neurotic disorders

4/25/2014

3



Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of (cont’d)

Substance-related disorders/addictive behavior

Somatoform disorders

Factitious disorders

Personality disorders

Patterns of violence/abuse/neglect

Organic psychoses

4/25/2014

4


Introduction

The mind and body are inseparable.

Illness affects a person’s behavior.

Changes in mental state affect physical health.

4/25/2014

5


Definition of Behavioral Emergency

Most experts define behavior as the way people act or perform.

Overt behavior is generally understood by those around the person.

Covert behavior has hidden meanings or intentions.

4/25/2014

6



Behavioral emergency

Some disorder of mood, thought, or behavior that interferes with ADLs

Psychiatric emergency

Behavior that threatens a person’s health or safety and the health and safety of another person

4/25/2014

7



A behavioral or psychiatric emergency is defined by the person who dials 9-1-1.

It can be difficult to understand the patient’s confused and frayed feelings.

4/25/2014

8


Prevalence

Average number of mentally unhealthy days for Americans has increased

1993: 2.9 days/month

Today: 3.5 days/month

45.1 million US adults with any mental illness in the past year

4/25/2014

9


Medicolegal Considerations

When behavior, speech, and thoughts are erratic, it can be difficult to communicate.

Spend time with the patient.

Obtain consent when possible.

Be clear in your explanations.

4/25/2014

10


Causes of Abnormal Behavior

Four broad categories

Biologic or organic in nature

Resulting from the environment

Resulting from acute injury or illness

Substance-related

4/25/2014

11



Biologic or organic

Organic brain syndrome

Conditions alter the functioning of the brain

4/25/2014

12



Environmental

Psychosocial and sociocultural influences

When consistently exposed to stressful events patients develop abnormal reactions.

Sociological factors affect biology, behavior, and responses to the stress of emergencies.

4/25/2014

13



Injury and illness

Illness results in stress on coping mechanisms.

Acute trauma creates stress.

Post-traumatic stress disorder (PTSD)

Courtesy of Captain David Jackson, Saginaw Township Fire Department

4/25/2014

14



Substance-related

Alcohol

Cigarettes

Illicit drugs

Other substances

4/25/2014

15


Psychiatric Signs and Symptoms

When mental health is challenged, mechanisms or behaviors work to return homeostasis.

Present as psychiatric signs and symptoms

4/25/2014

16


Psychiatric Signs and Symptoms

4/25/2014

17


Patient Assessment

Assessment of the patient with a behavioral emergency differs from other methods.

You are the diagnostic instrument.

The assessment is part of the treatment.

4/25/2014

18


Scene Size-Up

Situations with a strong behavioral component may have a sudden and unexpected turn of events.

Determine whether it is dangerous to you and your partner.

4/25/2014

19


Scene Size-Up

4/25/2014

20


Scene Size-Up

The environment can give clues.

Social history

Living conditions

Availability of support

Activity level

Medications

Overall appearance

Attitude/well-being

4/25/2014

21


Primary Assessment

Clearly identify yourself.

Form a general impression.

Assess appearance, posture, and pupils.

Limit the number of people around the patient.

Stay alert to potential danger.

4/25/2014

22


Primary Assessment

Airway and breathing

Assess the airway and evaluate breathing.

Provide interventions based on your findings.

4/25/2014

23


Primary Assessment

Circulation

Assess the pulse rate, quality, and rhythm.

Obtain systolic and diastolic blood pressures.

Evaluate for shock and bleeding.

Assess the patient’s perfusion level.

4/25/2014

24


Primary Assessment

Transport decision

Disturbed patients should see a physician.

If a patient withholds consent, they may be taken against their will at the request of:

Police

County mental health physician

4/25/2014

25


Primary Assessment

Transport decision (cont’d)

The same applies to the use of forcible restraint.

Law enforcement officers should be summoned.

Consult medical command as necessary.

4/25/2014

26


History Taking

Mental status examination

Key part of assessment

Check each system using COASTMAP.

4/25/2014

27


COASTMAP

Consciousness

Level

Concentration

Orientation

Year/month

Location

Activity

Behavior

Movement

Speech

Rate, volume, flow, articulation, and intonation

4/25/2014

28


COASTMAP

Thought

Is the patient making sense?

Memory

Recent

Remote

Immediate

Affect and mood

Do the inner feelings seem appropriate?

Perception

“Do you hear things others can’t?”

4/25/2014

29


Secondary Assessment

Obtain vital signs.

Examine skin temperature and moisture.

Inspect the head and pupils.

Note unusual odors on the breath.

4/25/2014

30


Secondary Assessment

In examining the extremities, check for:

Needle tracks

Tremors

Unilateral weakness or loss of sensation

4/25/2014

31


Reassessment

Routinely performed during transport

Your radio report should include:

Medical and mental health history

Medications prescribed

Assessment findings

Information from the mental status examination

4/25/2014

32


Reassessment

Discuss with the hospital the need for restraints or medications.

If the patient is aggressive or violent, provide advance notice to the emergency department.

4/25/2014

33


Emergency Medical Care

If the erratic behavior could be caused by a medical disorder:

Treat that before presuming the behavior is due to an emotional or psychiatric cause.

4/25/2014

34


Communication Techniques

Begin with an open-ended question.

Let the patient talk.

Listen, and show that you are listening.

© C

raig

Ja

ckso

n/I

nth

eD

ark

Ph

oto

gra

phy.c

om

4/25/2014

35



Don’t be afraid of silences.

Acknowledge and label feelings.

Don’t argue.

Facilitate communication.

Direct the patient’s attention.

Confrontation

4/25/2014

36



Ask questions.

Avoid “yes-no” or leading questions.

Use “how” and “what” questions.

Adjust your approach as needed.

4/25/2014

37


Crisis Intervention Skills

Be as calm and direct as possible.

Exclude disruptive people.

Sit down.

Preferably at a 45-degree angle

4/25/2014

38



Maintain a nonjudgmental attitude.

Provide honest reassurance.

Develop a plan of action.

Once the plan is set, allow the patient to exercise some control.

4/25/2014

39



Encourage some motor activity.

Stay with the patient at all times.

Bring all medications to the hospital.

Never assume that it is impossible to talk with any patient until you have tried.

4/25/2014

40


Physical Restraint

Improvised or commercially made devices

Be familiar with restraints used by your agency.

Make sure you have sufficient personnel.

Minimum of four trained, able-bodied people

4/25/2014

41


Physical Restraint

Discuss the plan of action before you begin.

Include law enforcement.

Use the minimum force necessary.

Don’t immediately move toward the patient.

4/25/2014

42


Physical Restraint

If the show of force doesn’t calm the patient, move quickly.

Grasp at the elbows, knees, and head.

Apply restraints to all four extremities.

The best position is supine.

4/25/2014

43


Physical Restraint

Never:

Tie ankles and wrists together

Hobble tie

Place a patient facedown in a Reeves stretcher

Once in place:

Don’t remove restraints.

Don’t negotiate or make deals.

Place a mask over the face of a spitting patient.

4/25/2014

44


Physical Restraint

Continuously monitor the patient.

Never place your patient face down.

Check peripheral circulation every few minutes.

© Jones & Bartlett Learning. Courtesy of MIEMSS.

4/25/2014

45


Physical Restraint

Be careful if a combative patient suddenly becomes calm.

Document everything in the patient’s chart.

You may defend yourself against an attack.

4/25/2014

46


Chemical Restraint

Use of medication to subdue a patient

Only use with approval from medical control

Follow local protocols and guidelines.

4/25/2014

47


Chemical Restraint

Haloperidol

Administered either IM or IV

Should not be administered to:

Patients younger than 14 years

Those with a suspected head injury

Those who may be pregnant

4/25/2014

48


Chemical Restraint

Benzodiazepines

Shorter-acting ones may be given intranasally.

Only midazolam and lorazepam have reliable intramuscular absorption.

Side effects are usually mild and easily treated.

4/25/2014

49


Chemical Restraint

Closely monitor the patient’s:

Pulse rate

Blood pressure

Respiratory rate

Be prepared to support ventilation.

4/25/2014

50


Pathophysiology, Assessment, and Management of Specific Emergencies

Many factors contribute to disturbances of behavior.

4/25/2014

51


Acute Psychosis

Pathophysiology

Person is out of touch with reality

Occur for many reasons

Episodes can be brief or last a lifetime.

4/25/2014

52


Acute Psychosis

Assessment

Characteristic: profound thought disorder

A thorough examination is rarely possible.

Transport the patient in an atraumatic fashion.

Use COASTMAP.

4/25/2014

53


Acute Psychosis

Consciousness

Awake and alert

Easily distracted

Orientation

Disturbances more common in organic disorders

Activity

Most commonly accelerated

Speech

Neologisms

4/25/2014

54


Acute Psychosis

Thought

Disturbed in progression and content

Memory

Relatively or entirely intact

Affect and mood

Mood is likely to be disturbed.

Affect may reflect mood or be flat.

Perception

Auditory hallucinations

4/25/2014

55


Acute Psychosis

Management

Reasoning doesn’t always work.

Explain what is being done.

Directions should be simple and consistent.

Keep orienting the patient.

4/25/2014

56


Acute Psychosis

Management (cont’d)

Before pharmacologic treatments, try:

Maintaining an emotional distance

Explaining each step of the assessment

Involving people the patient trusts

4/25/2014

57


Acute Psychosis

Management (cont’d)

When methods fail, it may be appropriate to:

Safely restrain the patient.

Administer a medication to help the behavior.

4/25/2014

58


Agitated Delirium

Pathophysiology

Delirium: a state of global cognitive impairment

Dementia: more chronic process

Patients may become agitated and violent.

4/25/2014

59


Agitated Delirium

Assessment

Try to reorient patients.

Perform a thorough assessment.

Management

Identify the stressor or metabolic problem.

4/25/2014

60


Suicidal Ideation

Pathophysiology

Suicide: any willful act designed to end one’s life

4/25/2014

61


Suicidal Ideation

Assessment

Every depressed patient must be evaluated for suicide risk.

Most patients are relieved when the topic is brought up.

4/25/2014

62


Suicidal Ideation

Assessment (cont’d)

Broach the subject in a stepwise fashion.

Higher-risk patients include patients who have:

Made previous attempts

Detailed, concrete plans

A history of suicide among close relatives

4/25/2014

63


Suicidal Ideation

Management

Don’t leave the patient alone.

Collect implements of self-destruction.

Acknowledge the patient’s feelings.

Encourage transport.

4/25/2014

64


Patterns of Violence, Abuse, and Neglect

Abuse and neglect

Assess the following:

The patient

The environment

Other persons involved

Document your findings, and report your concerns according to local protocols.

4/25/2014

65



Violence

Most angry patients can be calmed by a trained person who conveys confidence.

EMS personnel should prepare to deal with hostile or violent behavior.

Preventive action is best to ensure no harm.

4/25/2014

66



Identify situations with the potential for violence.

Preventive action starts with being prepared for a possible violent encounter.

Develop “survival awareness.”

4/25/2014

67



Risk factors

Scenarios including:

Alcohol or drug consumption

Crowd incidents

Violence has already occurred

People who are:

Intoxicated

Experiencing withdrawal

Psychotic

Delirious

4/25/2014

68



Warning signs include:

Posture: sitting tensely

Speech: loud, critical, threatening

Motor activity: unable to sit still, easily startled

Clenched fists, avoidance of eye contact

Your own feelings

4/25/2014

69



Management of the violent patient

Assess the whole situation.

Observe your surroundings.

Maintain a safe distance.

Try verbal interventions first.

4/25/2014

70


Mood Disorders

Unipolar mood disorder: mood remains at one pole of the continuum

Bipolar mood disorder: mood alternates between mania and depression

4/25/2014

71


Mood Disorders

Manic behavior

Patients typically have abnormally exaggerated happiness with hyperactivity and insomnia.

Pressured and rapid speech

“Tangential thinking”

Grandiose and unrealistic ideas

4/25/2014

72


Mood Disorders

Manic behavior (cont’d)

Be calm, firm, and patient.

Minimize external stimulation.

If the patient refuses transport, consult medical control.

4/25/2014

73


Mood Disorders

Depression

Leading cause of disability in people 15- to 44-year olds

Can occur in episodes with sudden onset and limited duration

Onset can also be insidious and chronic.

4/25/2014

74


Mood Disorders

Depression (cont’d)

Diagnostic features (GAS PIPES)

Guilt

Appetite

Sleep disturbance

Paying attention

Interest

Psychomotor abnormalities

Energy

Suicidal thoughts

4/25/2014

75


Schizophrenia

Typical onset occurs during early adulthood.

Experience may include:

Delusions

Hallucinations

A flat affect

Erratic speech

4/25/2014

76


Neurotic Disorders

Collection of psychiatric disorders without psychotic symptoms

Includes anxiety disorders

Mental disorders in which dominant moods are fear and apprehension

4/25/2014

77


Neurotic Disorders

Generalized anxiety disorder (GAD)

Patient worries for no particular reason or worrying prevents decision-making abilities.

Treated with pharmacologic agents and counseling

4/25/2014

78


Neurotic Disorders

Generalized anxiety disorder (GAD) (cont’d)

When dealing with a patient with GAD:

Identify yourself in a calm, confident manner.

Listen attentively.

Talk with the person about their feelings.

4/25/2014

79


Neurotic Disorders

Phobias

Unreasonable fear, apprehension, or dread of a specific situation or thing

Simple phobias focus all anxieties on one class of objects or situations.

4/25/2014

80


Neurotic Disorders

Phobias (cont’d)

When managing a patient, explain each step of treatment in detail.

4/25/2014

81


Neurotic Disorders

Panic disorder

Sudden feelings of fear and dread

If allowed to continue, panic attacks can cause severe lifestyle restrictions.

Agoraphobia: fear of going into public places

4/25/2014

82


Neurotic Disorders

Panic disorder (cont’d)

Signs and symptoms usually peak in 10 minutes.

4/25/2014

83


Neurotic Disorders

Panic disorder (cont’d)

Separate from panicky bystanders.

Provide a calm environment.

Be tolerant of the disability.

Reassure the patient.

Give the symptoms a name.

Help the patient regain control.

4/25/2014

84


Substance-Related Disorders

Regarded on four levels:

Substance use

Substance intoxication

Substance abuse

Substance dependence

Determining the most effective treatment requires an integrative approach.

4/25/2014

85


Eating Disorders

Persons may experience severe electrolyte imbalances.

Two thirds report anxiety, depression, and substance abuse disorders.

4/25/2014

86


Eating Disorders

Bulimia nervosa

Consumption of large amounts of food

Compensated by purging techniques

4/25/2014

87


Eating Disorders

Anorexia nervosa

Weight loss jeopardizes health and lives

Typical patient:

Decreased body weight based on age and height

Intense fear of obesity

Experience amenorrhea

4/25/2014

88


Somatoform Disorders

Preoccupation with physical health and appearance

Hypochondriasis: Anxiety or fear that the person may have a serious disease

Conversion disorders: a physical problem results from faking a physical disorder

4/25/2014

89


Factitious Disorders

Patient produces or feigns physical or psychological signs or symptoms.

Symptoms are under voluntary control.

Factitious disorder by proxy: a parent makes a child sick for attention and pity

4/25/2014

90


Impulse Control Disorders

Lack of ability to resist a temptation

Examples include:

Intermittent explosive disorder

Kleptomania

Pyromania

Pathologic gambling

4/25/2014

91


Personality Disorders

Maladaptive patterns of thinking about the environment and one’s self

Cause functional impairment or subjective distress

Be calm and professional.

4/25/2014

92


Medications for Psychiatric Disorders and Behavioral Emergencies

Patients may be taking any of several types of psychotropic drugs.

During your assessment, determine:

Which medications have been prescribed

Whether they are being taken

4/25/2014

93


Psychiatric Medication Types

Antidepressants

Combat the symptoms of depressive illness

Alter levels of neurotransmitters in the autonomic nervous system

4/25/2014

94



Antidepressants (cont’d)

Fluoxetine: the most commonly prescribed

Side effects are minimal.

Heterocyclic: used for major depression

Side effects are common.

4/25/2014

95



Antidepressants (cont’d)

Monoamine oxidase inhibitors: recommended for atypical major depressive episodes

Potential side effects

4/25/2014

96



Benzodiazepines

May be prescribed for severe emotional distress

Contraindicated in patients with:

Known hypersensitivity to benzodiazepines

Acute, narrow-angle glaucoma

First-trimester pregnancy

4/25/2014

97



Antipsychotics

Newer medications have less risk of adverse effects and are more effective.

Known as atypical antipsychotic (AAP) drugs

Relieve delusions and hallucinations.

Improve symptoms of anxiety and depression.

4/25/2014

98



Antipsychotics (cont’d)

May cause metabolic side effects

Cardiovascular effects depend on medication.

May cause an acute dystonic reaction

May cause atropine-like effects

4/25/2014

99



Amphetamines

CNS and PNS stimulants

Help with ADHD.

Raise systolic and diastolic blood pressure.

4/25/2014

100



Amphetamines

Psychological effects depend on:

Dose

Mental state

Personality

Results include:

Alertness

Elevated mood

Increased motor and speech activities

4/25/2014

101


Problems Associated with Medication Noncompliance

Increases the likelihood that a person with mental illness will commit a violent act

When obtaining medication history, include:

Previously prescribed medications

Missed doses

4/25/2014

102


Emergency Use of Medications

Emergency use of medications are often required with violence.

The potential danger is too great not to intervene.

4/25/2014

103


Emergency Use of Medications

Before administering chemical restraint, complete your assessment with:

A thorough understanding of the chief complaint

Attention to allergies

Medical and medication history

4/25/2014

104


Pediatric Behavioral Problems

50% of childhood mental illnesses will present by age 14 years.

More likely to have coexisting problems

Difficult to diagnose

© Leah-Anne Thompson/ShutterStock, Inc.

4/25/2014

105


Pediatric Behavioral Problems

Mental status assessment is similar to that of an adult.

Exception: Consider developmental level.

Abnormal findings are often related to adjustment disorders and stress.

4/25/2014

106


Geriatric Behavioral Problems

Distress and pain may be caused by:

Exposure to new experiences

Alterations to routines

© Leah-Anne Thompson/ShutterStock, Inc.

4/25/2014

107


Geriatric Behavioral Problems

Anxiety and depression are too often considered a “normal part of aging.”

Ageism: discrimination against older people

Take stock of your own attitudes.

4/25/2014

108


Summary

Behavioral emergencies can present unique challenges in patient management. Focus on reducing the patient’s stress without exposing yourself to unnecessary risks.

A behavioral or psychiatric emergency is any reaction to events that interferes with activities of daily living.

4/25/2014

109


Summary

Behavioral emergencies can be a temporary response to a traumatic event.

Calls for behavioral emergencies have special medical and legal considerations.

You have limited legal authority to require a patient to undergo care in the absence of a life-threatening emergency. Always involve law enforcement personnel when you are called to assist a patient with a severe behavior or psychiatric crisis.

4/25/2014

110


Summary

If a patient poses an immediate threat, leave the area until law enforcement personnel secure the scene.

Underlying causes of behavioral emergencies fall into four categories: biologic (organic) causes, causes resulting from the person’s environment, causes resulting from acute injury or illness, and causes that are substance related.

4/25/2014

111


Summary

Psychiatric signs and symptoms occur when mental health is challenged and psychological mechanisms or behaviors mobilize to return the person’s mental state to homeostasis.

Assessment of a disturbed patient differs from other assessment methods in that you are the diagnostic instrument. Assessment is also part of the treatment.

4/25/2014

112


Summary

When providing care, be direct, honest, and calm; have a definitive plan of action; stay with the patient at all times; and express interest in the patient’s story.

When sizing up the scene, pay special attention to potential dangers and objects that may be used as potential weapons, hazardous chemicals, etc. Remove potentially harmful objects.

4/25/2014

113


Summary

Primary assessment includes identifying yourself, forming a general impression of the patient’s condition and the nature of the problem, assessing the ABCs, making a decision about transport, and taking a history via the mental status examination.

Secondary assessment involves looking for signs of an organic cause of the behavioral emergency.

4/25/2014

114


Summary

Management is focused on ensuring scene safety and maintaining awareness of life-threatening conditions, while treating the patient for any medical disorders.

Effective communication techniques include beginning with an open-ended question, showing that you are listening, allowing silence when appropriate, avoiding argument, facilitating communication, and asking questions.

4/25/2014

115


Summary

Crisis intervention skills include staying calm and being direct, excluding disruptive people from the scene, maintaining a nonjudgmental attitude, developing a plan of action, encouraging motor activity, and assuming that the patient can hear and understand everything you say.

Use of chemical or physical restraints is reserved for times when verbal intervention fails to reduce severe agitation.

4/25/2014

116


Summary

Pathophysiologic factors that contribute to behavioral disturbances include cognitive impairment, thought disorders, mood disorders, neurotic disorders, substance-related disorders and addictive behavior, somatoform disorders, factitious disorders, impulse control disorders, and personality disorders.

4/25/2014

117


Summary

You may encounter patients with psychosis, a thought disorder characterized by a statue of delusion in which the person is out of touch with reality.

You may encounter patients with agitated delirium. This is impairment of cognitive function that can present with disorientation, hallucinations, or delusions, and is characterized by restless and irregular physical activity.

4/25/2014

118


Summary

The threat of suicide requires immediate intervention. Depression is the most significant risk factor for suicide.

Situations involving violence, abuse, and neglect can have the potential for escalation and the possibility of evoking emotional responses in you.

4/25/2014

119


Summary

Patients with psychiatric emergencies may be taking any of several types of psychotropic drugs. During assessment, determine which medications have been prescribed and whether the patient is actually taking them.

4/25/2014

120


Thank You

4/25/2014

121


psychiatry emergency ppt

Documents