Psychiatric Emergencies Flashcards
The Precautionary Principle
Prevent or minimize harm before it occurs
Psychiatric Code Team
ED physician, nurse(s), hospital nurse manager,
psychiatric clinical nurse, & security staff
* Ideally “assembled” in a prepped room
before patient arrival
De-escalation protocols:
- Respect Personal Space
– 2 arms length away - Do not provoke
– BE calm (verbal & non-verbal) - Establish Verbal Contact
– Only 1 person - Introduce yourself
– Orient & reassure - Be concise
– Keep it simple - Repetition
– Stay “on message” - Identify the wants & feelings
– Active listening - Read the patient’s communication
– Verbal & Non-verbal
– Active listening to communicate understanding - Miller’s Law
– “To understand what another person is saying, you must assume that it is
true and try to imagine what it could be true of.”
ER Triage Algorithm for psychiatric patients
- Ensure patient & ER safety, then
stabilize the patient - Identification of homicidal, suicidal, and/or
other dangerous behavior - Medical Evaluation
- Psychiatric diagnosis & severity assessment
- Psychiatric diagnosis & severity assessment established?
Seclusion rooms
- Permit rapid exit for staff
- Free of items used in violent
attacks - Panic button
- Door can lock from outside
- Security
Examination Rooms & Seclusion
- Secluded room → door open
- Advise patient of actions to be taken & the expected duration, & explain the
consequences of violent behavior. - If the patient remains agitated → lock the door.
- Monitor with a personal guard, nurse-monitor, or by closed–circuit television
- Give opportunities to show acceptable behavior → release from seclusion
- If violent behavior persists → restraint is justified
- Document all steps in the use of seclusion, medical & physical restraints
Physical Limb Restraints
- Applied by team
– 5 (Team lead, 1 person per limb) - Each carefully restrains the limb to the bed
- Elevate the patient head
- Offer medication first, then administer involuntarily
– Follow hospital protocol for observation & toileting - Removal
– Patient is calm & compliant
Signs & Symptoms of
Medically Related Behavioral Abnormalities
- Abnormal vital sign values
- Disorientation with clouded consciousness
- Abnormal mental status examination findings
- Recent memory loss
- Age >40 y without a previous history of psychiatric
disorder - Focal neurologic signs
- Visual hallucinations
Medically Related Behavioral Abnormalities examples:
- Diabetes Melitus (Hypoglycemia)
- CVD
- Pulmonary disease (Hypercapnia)
- Meningitis
- Drug withdrawal/overdose
- Other causes of delirium
– UTI (esp. elderly), hepatic encephalopathy
Mental Status Examination consists of the following
- Appearance & behavior
- Speech & language
- Mood & affect
- Thoughts & perceptions
- Cognitive function
Assessment of Harm to Self
- Establish rapport
- Assess suicidal intent,
current mental state, &
access to means of
suicide - Ensure a safety plan is in
place before discharge - Arrange f/u before D/C
SAD PERSONS
S Sex - M > F
A Age (13-18 & >75)
D Depression (behavioral health issues) Y or N
P Previous attempt - Y or N
E Ethanol use - Y or N
R Rational thinking loss - Y or N
S Social supports lacking - Y or N
O Organized plan - Y or N
N No spouse - Y or N (includes separation)
S Sickness (poor health) - Y or N
*Each factor is 1 point, & patients who score ≥5 points should be considered at high risk of suicide.
Red Flags for Assessment of Harm to Others
– Hostile behavior, homicidal ideas, fantasies, or
preoccupations
– Verbal aggressiveness, statements about violent intent
– Weapons skill & access
– Motives for violence
– Pre-attack planning & preparation
Involuntary Hospitalization
- Patients may be brought to the ER by the police or by the family because of suicidal ideation, homicidal ideation or due to other aberrant thoughts & behaviors.
- What if they will not consent to treatment?
- “First do no harm”
- A 72-hour involuntary mental health hold can
be obtained for the purpose of acute
evaluation & determination of the patient’s
safety when the evaluator elicits sufficient
information to confirm that a significant risk
exists of danger to self or others
Legal principles of involuntary hospitalization
- Parens Patriae: Latin, “parent of the country”
* Doctrine from English common law that assigns to the
government a responsibility to intervene on behalf of citizens who
cannot act in their own best interest. - Police Power:
1.The state must protect its citizens from injury by another
2.Providers have a duty to people other than their patients in only
very narrow circumstances
– clear & imminent threat to an identifiable person(s)
