Psychiatric Behavioral Emergencies Flashcards
Skills
Empathy
Do you really want to help this pt?
Act in their best interests?
Able to treat with dignity and respect?
Skills
Listening
What they say
How they say it
Skills
Observation
Body language and POSTURE
Agitation
Affect
Wisdom
- Behavioral emergencies may be due to medical illness
- Any illness or disease that creates a behavioral emergency needs treated
- ”Psych” patients are PATIENTS
- Many people suffer from psychiatric illness
- Chemical imbalances in the brain
Common Misconceptions
- Not true medical illness
- Mental disorders are incurable
- Always dangerous and violent; or bizarre
- Due to bad parents
- Personality Weakness
- Schizophrenia is “split personality”
- Depression is normal with aging
- Depression doesn’t affect kids or teens
- You can “will away” mental illness
- Having a mental disorder is cause for embarrassment and shame
- Addiction is a lifestyle choice
Behavior
•Normal vs Abnormal? -Measured against norms of society •Emergencies -Transient inability to cope -Is there danger to self or others? •Causes -Organic -Biological -Psychosocial -Socio-cultural -Injury -Substance related
Scene Survey
•Assess for: -violence -Substance abuse -Suicide attempt •Appearance and behavior -Psychomotor agitation -Hygiene, dress -Out of place -Body Posture •Limit number of people around pt •Stay alert to signs of possible danger
Body Posture
Shows attitude and frame of mind
Patient Contact
•Observe behavior •Posture -Tone/volume voice, facial expression, body position, tension •Personal space •Stand at angle •No sudden movement, do not surprise •Compassion w/o friendliness -Businesslike/calm •Schizophrenia - DO NOT cause agitation! •Limit number of people around pt
Speech/Thought
Form of thought
Ability to process information
Create logical ideas
Speech/Thought
Speech Rate
Mutism- refusing to answer
Poverty of speech- quick short answers (no elaboration)
Thought blocking- start to answer then stop part way through
Pressured- speaking a lot with no real pertinence to the question but just nonstop
Speech/Thought
Associations
Circumstantial thinking
Tangential thinking
Flight of ideas
Word salad
Speech
Thought Content
Psychosis
Distorted perception of reality
Thought Content
Hallucinations
False sensory- no bias in reality
Auditory- hearing voices
Visual- seeing things that aren’t there
Gustatory- metal taste
Touch
Olfactory- smells
Thought Content
Delusions
False perception of events, situations
Believes no matter what the evidence reveals
Thought Content
Neurosis
a relatively mild mental illness that is not caused by organic disease, involving symptoms of stress (depression, anxiety, obsessive behavior, hypochondria) but not a radical loss of touch with reality.
Thought Content
Paranoid Delusions
Persecution
Conspired against
Thought Content
Grandiose Delusions
Special powers
God-like
Thought Content
Somatic Delusions
Body
Thought Content
Delusions of Reference
Ordinary events have special, dangerous significance
Thought Content
Preoccupation
Ideas constantly dominate thoughts
Thought Content
Depersonalization
Detach self from body, mind, world
Like watching movie
Thought Content
Derealization
World is not real
Familiar things may seem alien, surreal
Affect
Outward expression of emotion; observed
-stable ➡️➡️ labile
Labile
Emotional expression characterized by hysterical laughter which quickly changes to sobbing
Flat Affect
Shows no emotion
Mood
Dominant sustained emotional state
Dysphoria
Depressed, sad, irritable
Euphoria
Elevated ecstatic
Euthymic
Normal
Physiological Changes
-New/changed/compliant medications?
-Substance abuse or misuse
-Rule out medical issues
-If acute crisis ➡️ consider medical causes
-Such as…
•other medical history
•Social history
•Is pt in danger of harming self or others?
Medications
Antipsychotics
Dopamine antagonists
Some also antihistamine
Anticholinergic properties
Medications
For Schizophrenia, delirium, acute psychosis
•Haloperidol (Haldol) •clozapine (Clozaril) •risperidone (Risperidone) •olanzapine (Zyprexa) •quetiapine (Seroquel) •Aripiprazole (Abilify) -Schizophrenia -Bipolar -Autism -Adjunct major depression
Antidepressants
Selective Serotonin Reuptake Inhibitors
SSRI
Citalopram (Celexa)
Escitalopram (Lexapro)
Paroxetine (Paxil)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Sertraline (Zoloft)
Antidepressants
Serotonin-norepinephrine reuptake inhibitors (SNRI’s)
Duloxetine (Cymbalta)
Venlafaxine (Effexor)
Antidepressants
Tricyclic Antidepressants (TCA’s)
Amitriptyline (Elavil) Nortriptyline (Pamelor) Protriptyline (Vivactil) Imipramine (Tofranil) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepine (Sinequan)
TCA’s
- Overdose = lethal arrhythmia
- Caution in elderly
Serotonin Syndrome
•2 or more serotonergic drugs combined -SSRI, SNRI, TCA, MAOI, St John’s wort, amphetamines, MDMA, cocaine, ondansetron, •Within 24 hr of taking •Very high body temps -Cooling measures •Seizures -Benzodiazepines •Extensive muscle breakdown -Supportive •Sweating, dilated pupils, agitation, diarrhea
Extra Pyramidal Symptoms (EPS)
Side affect from antipsychotic medications
•Blockage of Dopamine receptors in the brain
•Group of side effects
-Involuntary motor movement
-Uncontrollable muscle coordination
Tardive Dyskinesia
Degenerative neurologic disorder
Repetitive movements of mouth & face
-Sucking, chewing, grimacing, pouting
Rock back and forth, tap feet
Long-term use of antipsychotic drugs
Suppress dopamine pathways in brain
Patient not aware of movements
Dystonia
Abnormal muscle tone
Acute Dystonic Reaction
•Muscle spasms -Head/neck twists -Protrusion or swelling tongue -Muscular rigidity/contracture/twisting arm -Back arching -Restlessness, tremors •Onset- without warning •Young, males more often •Treat= Diphenhydramine 25-50 mg IV, IM •Causes= Antipsychotic drugs -Chlorpromazine (Thorazine), Prochlorperazine (Compazine), Haloperidol (Haldol)
Schizophrenia
Person has psychotic episodes that include hallucinations and delusions
Also, disorganized thoughts, impairment of reality testing
These symptoms occur for at least 6 months
Starts in late teens to mid 30’s. Can begin at age of 45
Thought Disorder
Schizophrenia
•Disorganized thoughts** -Word salad, loose association •Self care -Hygiene -Eating -Clothing •Social -Masturbate in public -Swear without reason -Flat affect -Inappropriate gestures -Unable to hold a job -Remain in rigid position for days •Hallucinations •Visual, tactile, olfactory •Auditory -Multiple voices -Say bad things -People out to kill them •Delusions -Persecution -Gesture, comments, song lyrics ➡️ directed toward them -Grandeur -Outside forces controlling them
Mood Disorders
Bipolar
•Manic state > 1 week •Irritation, anger •Labile •Maybe delusional •Can’t keep up with own thoughts -Torrential downpour of thoughts •Pressured speech •Loos associations
Mood Disorders
Major Depression
- Serotonin levels low?
- Dysphoria
- Melancholy
- Anhedonia
- Low self-worth, self-esteem
- Cognition, decisions difficult
- Sleep disturbances
- Appetite, libido altered
- Suicidal thoughts, plans
Major depression
Adult Findings
Withdrawal
Flat affect
Decreased cognitive functioning
Altered sleep
Physical pain
Major Depression
Pediatric Findings
Not obeying rules
Poor test scores
Lack of school participation (extracurricular)
Acute Anxiety Disorders
Panic Attack
Overwhelming fear
Apprehension
Impending doom
Acute Anxiety Disorder
Phobia
Intense fear of object or situation
May have no basis ➡️ irrational
Agoraphobia- “market place”
-Cannot escape the situation ➡️ home bound
Chronic Anxiety Disorders
Post Traumatic Stress Disorder PTSD
- Threat of death, injury or actual event
- Alternate emotional numbness with vivid memories and dreams
Chronic Anxiety Disorders
Obsessive Compulsive Disorder OCD
- Intrusive thoughts- obsessions
- Rituals- compulsions
Somataform Disorders
Conversion Disorder
- Psychological distress converted
- Motor or sensory symptoms
- Seizures
Somataform Disorders
Hypochondriasis
- Preoccupied with serious medical conditions
- Misinterpreting physical signs
- Despite medical evaluations
Factitious Disorders
•Intentional s/s to feign illness •Knowledgeable of the illness •Munchausen Syndrome •Munchausen by proxy -Illness/injury inflicted upon another -Mother to child •Malingering -Feign illness or injury for gain
Eating Disorders
Anorexia Nervosa
-Distorted body image •Refuses to eat normally -Think they are obese •Measure themselves or look into mirror •Self esteem is dependent upon body image •Weight loss is good discipline •Don’t recognize they have a problem
Eating Disorders
Bulimia Nervosa
•Binges on food ➡️ then purges -Enormous amounts of food in 2 hr -Vomiting, laxatives, diuretics -Exercise or fast for days •High calorie food (cake) •Binge in secret -Becomes depressed •Average weight •Low self-esteem •Electrolyte and cardiac arrhythmias •Esophageal tears, gastric rupture
Personality Disorders
Paranoid
Distrust and suspicion of others going to harm.
Pervasive, ongoing pattern of suspicion
Personality Disorders
Schizoid
Pattern of detachment from social relationships and limited emotions
Eccentric
Solitary
Disinterested in social interaction
Personality Disorders
Antisocial
Disregard for, violation of rights of others
Pervasive, impoverished moral sense or lack of moral conscience
Personality Disorders
Borderline
Instability in relationships,self-image, and impulsive
Acts impulsively
Personality Disorders
Histrionic
Shows excessive emotion and attention seeking behavior
Theatrical
Dramatic
Personality Disorders
Narcissistic
Pattern of grandiosity, need for admiration and lack of empathy
Preoccupied with self
Personality Disorders
Avoidant
Social inhibition
Feeling of inadequacy
Sensitive to criticism
Personality Disorders
Dependent
Excessive need to be taken care of and will submit to others for fear of separation
Personality Disorders
Obsessive Compulsive
Need orderliness and perfectionism
Impulse Control Disorders
- Inability to resist impulse or temptation
- Pathological gambling
- Kleptomania- urge to steal
- Pyromania- urge to burn
- Trichotillomania- pulling out hair
Suicide
•Act of ending one’s own life •Suicide ideation- thought, fantasy, plans •Attempt- unsuccessful effort •History of: -Self-injury •Mutilation, cutting •Aim ➡️ bring back some feeling or “pain” high •Less than 45 - frequent attempts •Older than 60 - more likely to succeed •Females- attempt more often •Males- succeed more often •Firearms- most common method
Suicide Assessment & Treatment
•Scene safety •Suicide attempt? Vs Ideation? -Ethical and legal responsibility to provide help •Attempt- -Life-threats •After life-threats managed: -Respect -Listen -Dignified transport
Verbal Restraint
•Gather YOUR wits first •Use low voice, identify yourself •Acknowledge pt’s behavior •Encourage pt to talk ➡️ then LISTEN •Ask ➡️ - “Do you feel like you will lose control?” - “Are you carrying any weapons?” •Set limits on their behavior •Back off and get help •Don’t attempt “talk down” -Uncontrollable/ unknown chemicals/ situation involved
Restraint Methods
•Begin with gentle, non threatening approach
•Progress as needed
•Explain options to patient before force is used
-Last resort- harm to self or others
•Assess surrounding before starting restraint
•Do not enter pt’s physical space until all involved in restraint action are ready
-5 people minimum
•Be familiar with restraint devices
•Handcuffs- officer MUST ride with you!
Physical Restraints
•Physically restrained pt’s may require chemical restraints •Excited delirium •Pattern- watch for: -Delirium & violent -Calm / quiet for short period -Respiratory/cardiac arrest -Asystole -Doesn’t respond to ACLS treatment
Chemical Restraints
Lorazepam (Ativan)
- 2 mg IM/IV
- Respiratory depression
- Hypotension
Chemical Restraints
Haloperidol (Haldol)
- 5-10 mg IM/IV
- Respiratory rate
- Acute dystonic reaction
- Prolonged QT/ torsades
- Mental status changes
Anhedonia
Lack of enjoyment in activities that were once pleasurable
Chemical Restraint
Ketamine
•Quicker
- 4-5 mg/kg IM
- Acts in 3 min
- 1-2 mg/kg IV
- Onset 30 sec
Chemical Restraints
B-52
50 mg of Benadryl (separate syringe) \+ 5 mg Haldol \+ (in same syringe) 2 mg Ativan
