Definition of Psychiatric Emergencies

Psychiatric emergencies are situations that require immediate attention.  They are acute psychiatric problem that could lead to a serious outcome, such as self-harm or violence.

Psychiatric emergencies encompass situations in which an individual cannot refrain from acting in a manner that is dangerous to themselves or to others. The patient may be aware of the danger their behaviour poses (as with an overdose with the intent to die) or they may lack insight into the effects of their actions (as in the case of a manic patient who engages in reckless sexual behaviour). In other cases, the patient perceives that their actions are dangerous, yet they continue engaging in these behaviours despite the risks. For example, a patient with schizophrenia who follows command hallucinations to commit theft. Because of their lack of insight and judgment, individuals experiencing psychiatric emergencies are often brought to the attention of medical professionals by people in their community, including friends, family, police officers, or even bystanders.

You may also encounter psychiatric emergencies during routine outpatient care. Patients may report their inability to remain safe, either spontaneously or as established by a nurse or a psychiatrist.

In this unit, we will discuss the nature and management of the following psychiatric emergencies:

1. Suicide or deliberate self-harm

2. Violence or excitement

3. Stupor and catatonic syndrome

4. Panic attacks

5. Withdrawal symptoms of drug dependency

6. Alcohol or drug overdose

7. Delirium

8. Severe depression

9. Iatrogenic emergencies

Let us start by looking at suicide.

1. Suicide or Deliberate Self-Harm

Definitions

Suicide is death caused by injuring oneself with the intent to die. A suicide attempt is when someone harms themselves with any intent to end their life, but they do not die as a result of their actions.

Parasuicide is the apparent attempted suicide without the actual intention of killing oneself.

A failed suicide attempt (Latin: tentamen suicidii), or nonfatal suicide attempt, is a suicide attempt from which the actor survived (Townsend, 2005).  Attempted suicide is a serious situation.

Suicide attempts are usually categorised into two groups:

• Attempts by those who intend to take their lives and wish to die.

• Attempts by those who make impulsive suicide gestures or harm themselves deliberately.

The latter attempts are categorised as parasuicide, but it is important to remember that both groups are at serious risk for successful future suicide attempts.

Risk Factors for Suicide

Demographic Factors

• ·Males have a higher rate of completed suicide than females.

• ·Older people are at a higher risk for completed suicide than those of a younger age.

• ·Completed suicide is much more likely to take place in the two extreme ends between the rich and privileged and the poor and underprivileged.

• ·Some occupations such as doctors or police officers, provide easy access to the means for completing suicide.

Biomedical Factors

• People with serious physical illnesses are more at risk for suicide than others because of the pain and anguish they have to endure over longer periods of time.

• Some people may be biologically predisposed to the risk for suicide. 

Psychiatric Factors

• Suicide ideas are more common in people who are depressed.

• Abuse of alcohol and other psychotropic drugs may impair a person’s judgment in terms of controlling impulsive and risky behaviour.

• People with major mental illnesses such as schizophrenia and mania are also at greater risk for suicide because of the ‘commanding voices or hallucinations they may experience in the course of the illness and as a result of impulsive and risky behaviour seen in manic patients.

Psychosocial Factors

• • Individuals with personality disorders such as borderline personality traits have a higher risk for suicide.

  • A history of previous suicide attempt or history of suicide indicates a higher risk.

  • Stressful life events such as the loss of a loved one, unemployment, and divorce among others may predispose someone to attempt suicide.

Types of Suicide

According to Emile Durkheim (Pickering & Walford, 2011), the term suicide is applied to all cases of death resulting directly or indirectly from a positive or negative act of the victim, which he/she knows will produce this result. Durkheim identifies four different types of suicide, which are egoistic suicide, altruistic suicide, anomic suicide and fatalistic suicide. Let us look at each type in turn, starting with egoistic suicide.

A. Egoistic Suicide

This is seen as stemming from the absence of social integration. This type of suicide results from individuals feeling like social outcasts and seeing themselves as isolated or outsiders. These individuals are unable to find their own place in society and have problems adjusting to groups. They received little to no social care. Suicide is seen as a solution for them to free themselves from loneliness or excessive individuation.

B. Altruistic Suicide

This occurs when social group involvement is too high. Individuals are so well integrated into the group that they are willing to sacrifice their own life in order to fulfil some obligation to the group. Individuals kill themselves for the collective benefit of the group or for the cause that the group believes in. Examples of people who have committed suicide for the sake of a religious or political cause include the infamous Japanese Kamikaze pilots of World War II, or the terrorists that crashed airplanes into the US World Trade Centre, the Pentagon, and a field in Pennsylvania in 2001. During World War II, Japanese Kamikaze pilots were willing to lay down their own lives for their countries in the hope that they would win the war. These pilots believed in their nation’s cause and were willing to sacrifice their lives. Similarly, suicide bombers around the world are willing to give up their lives in order to make a political or religious statement because they firmly believed in their group’s cause.

C. Anomic Suicide

This is caused by a lack of social regulation and it occurs during high levels of stress and frustration. Anomic suicide stems from sudden and unexpected changes in situations. For example, when individuals suffer extreme financial loss, the disappointment and stress they face may drive them towards committing suicide as a means of escape.

D. Fatalistic Suicide

This occurs when individuals are kept under tight regulation. These individuals are placed under extreme rules or high expectations are set upon them, which removes their sense of self or individuality. Slavery and persecution are examples of situations that can lead to fatalistic suicide, because individuals may believe they are destined by fate to be in such conditions and believe suicide is the only means of escape. Another example is the effect of rigid or stifling societal expectations. In South Korea, a singer known as Kim Jonghyun committed suicide due to exhaustion from keeping up with society’s rules and regulations. He ended his life due to severe depression and the pressure of being in the spotlight as he felt that he could not fulfil the society’s expectations of his performance (Lee, 2018).

Assessment of Suicide Risk

It is important to undertake a thorough assessment of a patient that has attempted suicide to determine whether the patient is at imminent risk for a further attempt. Information about risk factors needs to be obtained and documented for every patient attempting suicide, regardless of whether the attempt was potentially lethal or not.

Following a suicide attempt, it is important to interview family as well as close friends and others, where appropriate, in order to obtain comprehensive information leading to the attempt as well as verifying the accuracy of the patient’s story.

After a suicide attempt, the following information needs to be obtained in order to establish whether the patient is in imminent danger of another attempt:

·         Did the patient wish to die?

·         Was the attempt pre-meditated or planned?

·         Was the attempt hidden from others and undertaken in a place where the individual was unlikely to be found?

·         Had the patient put their affairs in order in preparation for death (for example, made a will)?

·         Did the patient communicate an intention to die before the attempt, or leave a note?

·         Was the patient under the influence of drugs or alcohol at the time of the attempt?

Note that a positive response to any of these questions is indicative of high risk for a further attempt, and the patient will require urgent hospitalisation.

Management of a Suicide Attempt

Patients who are evaluated as high risk for further suicide attempts must be admitted to a psychiatric hospital immediately. Hospitalisation of an actively suicidal patient is usually accomplished by means of an involuntary admission. The Mental health Act No.6 of 2019 makes allowances for a doctor to transfer a severely mentally ill patient to a psychiatric hospital. Once in hospital, a decision is made whether to keep the patient contained in a closed ward facility in order to ensure a safe environment while they are actively suicidal.

It is important to provide ongoing supportive counselling for any patient who makes a suicide attempt in a crisis situation. Regular counselling sessions provide an opportunity to review the mental state and risk of suicide, and to support the patient through a stressful period. If there is concern about a possible further attempt, an agreement or contract with the patient is a tool that can be used. The contract states that the patient will not carry out any suicidal act, and will contact the named caregiver or nurse in the event of feeling desperate and suicidal. This contract is binding for both parties where the patient undertakes to seek constructive help when in despair, and the nurse is committed to providing the appropriate support.

The patient’s behaviour is closely monitored to identify any intent to commit self-harm. With the patient’s permission and where appropriate, the involvement of close family members may be helpful in monitoring and supporting the patient. If the patient is assessed as depressed or anxious, it will be necessary to administer prescribed anxiolytic medication and antidepressants to alleviate the distressing symptoms.

2.Violence or Excitement

Aggression or violence arises from an innate drive or occurs as a defence mechanism and is manifested either by constructive or destructive acts directly towards self or others. Aggressive people ignore the rights of other people. They must fight for their own interests and they expect the same behaviour from others. An aggressive approach to life may lead to physical or verbal violence. The aggressive behaviour often covers a basic lack of self-confidence. Aggressive people enhance their self-esteem by overpowering others, thereby proving their superiority. They try to cover up their insecurities and vulnerabilities by acting aggressively.

What is the difference between Anger and Aggression?

• Anger is defined as a strong uncomfortable emotional response to provocation that is unwanted and incongruent with one’s values, beliefs or rights.

• Aggression refers to behaviour that is intended to cause harm or pain. Aggression can be either physical or verbal.

Characteristics of Aggressive Behaviour

• Aggressive behaviour is communicated verbally or non-verbally.

• Aggressive people may invade the personal space of others.

• They may speak loudly and with greater emphasis.

• They usually maintain eye contact over a prolonged period of time so that the other person experiences it as an intrusive.

• Gestures may be emphatic and often seem threatening. For example, they may point their figure, shake their fists, stamp their feet or make slashing motions with their hands.

• Posture is erect and aggressive people often lean slightly forward towards the other person. The overall impression is one of power and dominance.

Types of Aggression

a.    Instrumental aggression. This is aggression aimed at obtaining an object, privilege or space with no deliberate intent to harm another person.

b.    Hostile aggression. This is aggression intended to harm another person by hitting, kicking, or threatening to beat up someone.

c.    Relational aggression. This is a form of hostile aggression that damages peer relationships, for example, in social exclusion or rumour spreading.

Predisposing Factors to Aggressive Behaviour

a. Genetic Factors

• • Aggressive behaviour is more likely to be inherited and as such, it is considered a familial trait.

  • Chromosomal influences: XYY syndrome contributes to aggressive behaviour. A person with this syndrome is often tall, below average intelligence and likely to be in conflict with the law.

b. Neurophysiological Disorders

Epilepsy that originates in the temporal lobe and frontal lobe results in episodic aggression and violent behaviour. Tumours in the brain, particularly in the areas of the limbic system and the temporal lobe, trauma to the brain resulting in cerebral changes diseases such as encephalitis have been implicated in the predisposition to aggression and violent behaviour.

c. Psychological Factors

Several mental health conditions can be associated with aggressive behavior, including:

• Attention-deficit/hyperactivity disorder (ADHD)

• Bipolar disorder

• Borderline personality disorder (BPD)

• Narcissism

• Post-traumatic stress disorder (PTSD)

Epilepsy, dementia, psychosis, substance use disorder, and brain injuries or abnormalities can also influence aggression.

d. Intrinsic Behaviours

·         Freud’s View

Sigmund Freud held the view that all human behaviour stems either directly or indirectly from two instincts. In this framework, aggression was simply viewed as a reaction to blocking or thwarting of libidinal impulses and was neither an automatic nor an inevitable part of life. According to Freud, aggression primarily stems from the redirection of the self-destructive death instincts away from the self and towards others.

 ·         Learned Behaviour

According to learning theory, aggression is primarily a learned form of social behaviour. Learning aggressive behaviour occurs by observation and modelling. For example, a child watches an angry parent strike out another person. Learning aggressive behaviour also takes place by direct experiences. The person feels anger and behaves aggressively. If behaving aggressively brings rewards, the behaviour is encouraged.

e. Social Factors

·         Frustration

The single most potent means of inciting human beings to aggression is frustration. This hypothesis indicates that frustration always leads to a form of aggression and that aggression always stems from frustration. However, frustrated people do not always respond with aggressive thought, words, or deeds. They may show a wide variety of reactions ranging from resignation, depression and despair to attempts to overcome the sources of frustration.

 ·         Direct Provocation

Evidence indicates that physical abuse and verbal taunts from others often elicit aggressive actions.

 ·         Observational Learning

In this case, observers acquire new means of harming others not previously present in their behaviour.

 ·         Disinhibition

A person’s restraint or inhibition against performing aggressive action is weakened as a result of observing others engaging in such behaviour.

 f. Environmental Factors

It is believed that people exposed to loud, irritating noise direct stronger assaults against others than those not exposed to such stimuli. How one was raised may play a role in whether or not you engage in aggressive behavior. People who grow up witnessing aggression may be more likely to believe that violence and hostility are socially acceptable. Experiencing trauma during childhood can also lead to aggressive behavior in adulthood.

Nursing Management of Aggressive Patients

As you may be aware, nurses provide care for patients with many types of problems. Patients are often in great distress and exhibit many maladaptive coping responses. Nurses who work in emergency rooms, critical care areas and acute psychiatric wards often care for people who respond to events with anger and aggressive behaviour that can pose a significant risk to themselves, other patients and health care providers. Thus preventing and managing aggressive behaviour are important skills for all nurses to have.

General Principles of Management

• The safety of the patient, clinician, staff, other patients and potential intended victims is of most importance while looking after aggressive patients.

• The doors should open outwards and not be lockable from inside or capable of being blocked from inside.

• While working with impulsively aggressive or violent patients in any setting one must take care to reduce patient’s access to harmful objects as well as jewellery and other attire that might add to the risk of injury during an assault, including neckties, necklaces, earrings, eyeglasses, lamps and pens.

• The availability of appropriate supervision is a critical safeguard in the treatment of potentially dangerous patients.

• The nurse may choose to communicate a few key observations in a calm and firm but respectful manner. The nurse should also put space between self and patient, avoid physical or verbal threats, avoid making false promises and work on building rapport with the patient.

• Patients with a high risk for violent behaviour should be physically restrained.

Drug Treatment of Aggressive and Violent Behaviours

Careful diagnosis is required to avoid overuse and misuse of medication. Medications are used primarily for two purposes:

·    To use sedating medication in an acute situation to calm the patient to prevent them from harming self or others.

·    To use medication to treat chronic aggressive behaviour.

Factors influencing the choice of drugs are availability of an intramuscular (IM) injection, speed of onset and previous history of response.

Acute Agitation and Aggression Treatment

Antipsychotic medication: the sedating property of antipsychotic medication is often what produces the calming effect on the patient.

• Atypical antipsychotic medication is also commonly used but only Ziprasidone is available in intramuscular form.

  • Haloperidol-1 mg or 0.5 mg IM

  • Risperidone 0.5mg-1mg: given in cases of dementia and schizophrenia.

  • Trazodone:  50-100mg given to older clients with sun downing syndrome and aggression.

• Benzodiazepines: used due to the sedative effect and rapid action. Lorazepam, oral or injection, is most commonly used. Other sedating agents used include valproate, chloral hydrate and diphenhydramine.

3. Stupor and Catatonic Syndrome

Stupor occurs when a person feels completely immobile, unable to speak, walk or function. They do not respond to stimuli.

Catatonia is a psychomotor disorder that involves the link between mental function and movement.

Stupor is a symptom of catatonia. It can last for hours, months, days or even years. There are many different types of catatonia. It is triggered by psychotic disorders, bipolar disorders, depressive disorders, neurodevelopment disorders and other medical conditions.

Management

Treating such disorders is difficult, hence, you should acknowledge the patient’s pain and empathise with them. Console them using tactile functions. Encourage group therapy and listen attentively.

4. Panic Attacks

What is a panic attack?

Panic attacks are sudden surges of overwhelming fear and anxiety, which get the better of the patients and make them feel like they are on the brink of death. In that moment, they feel overwhelmed by a cloud of anxiety and stress and their heart races as if it is about to stop. For some people, the condition is so severe that they experience difficulty breathing. Some people are dumbfounded in that moment and cannot move their body. Sweating and shivering kicks in and if proper medication is not administered, the condition gets worse. In this section, we will discuss the diagnosis of panic attacks/disorders, their cause, their treatment in emergency rooms and how to remain calm and relaxed in case of a panic attack.

Causes of Panic attacks

Panic attacks are brought about by situations and incidents where one feels endangered or unable to escape. For people however, panic attacks can result from constantly thinking about certain problems they are facing in life. The idea of something bad happening to you in the near future triggers responses from your body. These responses are different in people and although some are able to remain calm and relaxed, others lose it and are overwhelmed by anxiety and fear. Some people experience recurrent panic attacks every time they are faced with specific situations or are supposed to carry out a certain activity like visit a dentist for example. Prolonged panic leads to the development of panic disorders, which are more dangerous.

Signs and Symptoms of Panic Attacks

As we mentioned earlier, the signs and symptoms of panic attacks vary from one person to another. The intensity of the signs and symptoms is determined by response of an individual’s body when faced with certain situations.

The most common symptoms of panic attacks include the following:

• Increased heart beats where the heart palpitates

• Chest pains

• Shivering

• A weird choking feeling

• A feeling of being detached from the surroundings

• Profuse sweating

• Nausea

• Vomiting

• Feeling light-headed

• Numbness.

• Some people will even pass stool or urinate on themselves during panic attacks because they are extremely shocked and lose it.

Some people may only experience relatively mild symptoms such as racing hearts and perhaps profuse sweating. They can better cope with panic attacks than those who experience relatively extreme symptoms. If someone experiences panic attacks repeatedly then there is the possibility of developing a panic disorder. If an individual is worried about having another panic attack, they should seek medical help for their panic disorder at the nearest emergency room.

Treatment of Panic Attacks

There are three main treatment options available in emergency rooms for panic attacks. These are:

• Cognitive behavioural therapy

• Exposure therapy

• Medication.

Cognitive Behavioural Therapy

In cognitive behavioural therapy, the thinking patterns and behaviours that trigger the panic attacks are addressed. With help from the counsellor, the patient explores the consequences of the situations until they understand that their reactions are based on fear and not reality. The moment the patient feels comfortable about these situations, they will be able to remain calm and relaxed if they are faced with similar situations in the future.

Exposure Therapy

Here, the patient is exposed to the physical sensations of panic but in a controlled environment enabling the body to cope with the conditions and learn to respond in a better way. The patient is asked to take part in exercises that trigger similar sensations as those they experienced during the panic attack. With each passing exercise, they become used to the sensations and get a sense of control over the overwhelming fear and anxiety. In case of a panic attack, they are able to remain calm and see the problem through without much worry.

Medication

Medication is used when the patient’s symptoms are severe and the patient is in danger. Some of the most common drugs used to treat panic attacks and disorders include antidepressants and benzodiazepines. These are anti-anxiety drugs whose effects kick in within minutes and help relieve the panic and other attack symptoms. The only shortcoming of such drugs is the fact that they can be addictive and can have some extreme withdrawal symptoms. For better results, these drugs are used limitedly in conjunction with the other two treatment options.

Nursing Management

Nursing management of a patient with anxiety disorder include the following:

A. Nursing Assessment

Nursing assessment of a patient with anxiety disorder include:

• History. The client usually seeks treatment for panic disorder after he or she has experienced several panic attacks; usually, the client cannot identify any trigger for these events.

• General appearance and motor behavior. The client may appear entirely “normal” or may have signs of anxiety if he or she is apprehensive about having a panic attack in the next few moments.

• Mood and affect. Assessment of mood and affect may reveal that the client is anxious, worried, tense, depressed, serious, or sad.

• Thought processes and content. During a panic attack, the client is overwhelmed, believing that he or she is dying, losing control, or “going insane”; the client may even consider suicide.

• Sensorium and intellectual process. During a panic attack, the client may be confused and disoriented; he or she cannot take in environmental cues and respond appropriately.

B. Nursing Diagnosis

Based on the assessment data, the major nursing diagnosis are:

• Anxiety related to unconscious conflict about essential values and goals of life; situational or maturational crises.

• Fear related to phobic stimulus.

• Ineffective coping related to underdeveloped ego; punitive superego.

• Powerlessness related to fear of disapproval from others.

• Social isolation related to panic level of anxiety.

C. Nursing Care Planning and Goals

The major nursing care planning goals for patients with anxiety disorders  are:

• Client will verbalize ways to intervene in escalating anxiety within 1 week.

• Client will be able to recognize symptoms of onset of anxiety and intervene before reaching the panic stage by time of discharge from treatment.

D. Nursing Interventions

The nursing interventions for anxiety disorders are:

• Stay calm and be nonthreatening. Maintain a calm, nonthreatening manner while working with client; anxiety is contagious and may be transferred from staff to client or vice versa.

• Assure client of safety. Reassure client of his or her safety and security; this can be conveyed by physical presence of the nurse; do not leave client alone at this time.

• Be clear and concise with words. Use simple words and brief messages, speak calmly and clearly, to explain hospital experiences to client; in an intensely anxious situation, client is unable to comprehend anything but the most elementary communication.

• Provide a non-stimulating environment. Keep immediate surroundings low in stimuli (dim lighting, few people, simple decor); a stimulating environment may increase level of anxiety.

• Administer medications as prescribed. Administer tranquilizing medication, as ordered by physician; assess medication for effectiveness and for adverse side effects.

• Recognize precipitating factors. When level of anxiety has been reduced, explore with client possible reasons for occurrence; recognition of precipitating factors is the first step in teaching client to interrupt escalation of anxiety.

• Encourage client to verbalize feelings. Encourage client to talk about traumatic experience under nonthreatening conditions; help client work through feelings of guilt related to the traumatic event; help client understand that this was an event to which most people would have responded in like manner.

5. Withdrawal Symptoms of Drug Dependency

Withdrawal symptoms are Physical and mental symptoms that occur after stopping or reducing intake of a drug. The characteristics of withdrawal depend on what drug is being discontinued.

Symptoms may include anxiety, fatigue, sweating, vomiting, depression, seizures and hallucinations.

Treatment includes supportive care as well as medication to address symptoms and prevent complications.

Mild symptoms of alcohol withdrawal include:

•  Shaking 

•  Mild sweating

• Mild anxiety

• Fatigue

• Headaches

• Insomnia

• Nausea

• Vomiting

• Irritability

More severe symptoms include:

·         High blood pressure

·         Elevated body temperature

·         Elevated heart rate

·         Irregular heartbeat

·         Seizures

·         Tremors

·         Alcohol withdrawal depression

·         Altered consciousness

·         Hallucinations

Clinical Management of Withdraw Symptoms

Benzodiazepines are the first-line therapy. They decrease the incidence of seizures and delirium tremens. Chlordiazepoxide (LIBRIUM) administered for 5-7 days or fixed dose diazepam regime can be administered.

Carbamazepine is an appropriate alternative to benzodiazepine in the outpatient treatment of patients with mild to moderate alcohol withdrawal symptoms. Medications such as haloperidol, beta-blockers, clonidine, and phenytoin may be used as adjuncts to a benzodiazepine in the treatment of complications of withdrawal.

Intravenous fluids such as 5 percent dextrose are helpful in maintaining fluid balance and preventing hypoglycaemia. Vitamin B1 (thiamine) is also administered to prevent memory problems.

6. Alcohol and Drug Overdose

When someone binge drinks or takes in a lot of alcohol over a short amount of time, their blood alcohol level becomes very high the person develops alcohol toxicity or poisoning. Alcohol intoxication is characterised by a person becoming  disoriented, unresponsive, extremely confused, experiencing shallow breathing, and may pass out or go into a coma. Alcohol intoxication or poisoning is life threatening when not treated urgently.

A common cause of alcohol poisoning is binge drinking. Although less common, it also occurs when somebody drinks household products containing alcohol.

When alcohol is consumed, it is filtered from the bloodstream by the liver. Alcohol is absorbed faster into the bloodstream than food. The liver is only able to process a limited amount. In fact, only one unit of alcohol every hour is processed through the liver. Whenever there is more than one unit consumed within an hour, this means there are extra units of alcohol in the bloodstream. The faster someone drinks, the higher their blood alcohol concentration (BAC) increases.

Drinking too much alcohol over a short period of time subsequently elevates BAC and both physical and mental tasks become harmfully affected. Breathing, heartbeat and gag reflex are some of the reactions to elevated BAC. Someone may choke, be unable to breath, and develop heart arrhythmia. Vital physical functions can stop working and the person can stop breathing and lose consciousness (passes out).

The population at highest risk of developing alcohol poisoning are college students, chronic alcoholics, people on medication that contraindicate with alcohol, adolescents experimenting and accidental consumption of household products by younger children.

Alcohol Intoxication Symptoms

Blood alcohol concentration (BAC) continues to rise half an hour to forty minutes after the last drink which can make symptoms worse.

The symptoms of alcohol intoxication are:

·         Major decrease in reaction time or no reactions.

·         Loss of consciousness or deep sleep.

·         Problems with breathing.

·         Weak pulse.

·         Repeated vomiting.

·         Excessive sweating.

·         Skin that is moist or cold to the touch (hypothermia).

Assessment of Alcohol Intoxication

Confirmation of suspected alcohol intoxication can be informed by:

·         Direct communication:  the person informs staff that they have been using alcohol.

·         Through observation of the person, for example, smells of alcohol, disinhibited behaviour, and slurred speech.

·         An alcoholmeter, when available, should always be used to confirm alcohol use (patient compliance allowing) followed by periodic measurements to establish ongoing alcohol breath level. The readings will give an accurate indication of alcohol breath level.

The use of an alcoholmeter aids the confirmation of alcohol NOT the level of intoxication.

Management of a Patient with Alcohol Intoxication

In severe cases of alcohol poisoning the following can occur:

• Choking on one’s own vomit which can stop breathing completely or cause a heart attack. Hypothermia which is dangerous, as there is risk of brain damage.

• Fits or seizures can also occur when blood glucose levels drop below the normal range.

• Extreme cases of alcohol poisoning can result in coma, sometimes leading to death.

Once a patient has been admitted to the hospital for alcohol poisoning, the medical team may only monitor them until alcohol levels have dropped. An airway or tube may be inserted into the windpipe to help with breathing. They also may have an I.V. drip to assist with hydration, blood glucose and vitamin levels. Catheters are inserted for patients that have become incontinent. In severe cases where BAC levels are very high and symptoms are severe, the patient’s stomach may be pumped. Stomach pumping involves the flushing of fluids through a nasal-gastric tube that goes down the patient’s mouth or nose. 

Drug Overdose (Poisoning)

Drug poisoning or intoxication is a condition that follows the use of psychoactive substances or drugs of abuse such as heroin, cocaine and many others. It results in disturbance of levels of consciousness, impaired cognition (thought process), altered perception and behavioural changes and other changes to psycho-physiological functions and responses (World Health Organisation [WHO], 1994). This occurs because of the acute pharmacological effect of the substance.

It is important for you to note that the state of intoxication will resolve in time with complete recovery. However, there are complications/risks associated with the intoxicated state such as trauma, inhalation of vomitus, coma. If these are not properly managed, they may result in longer-term complications or possibly death.

Assessment of Drug Overdose

Confirmation of suspected drug overdose can be informed by:

• Direct communication:  the patient informs staff that they have been using illicit substances.

• Through observation of the person, for example, disinhibited behaviour and slurred speech.

• An examination of the patient’s mental health should systematically aid the detection of the presence of signs indicative of acute poisoning or intoxication.

• The use of urine ‘dip sticks` according to manufacturer’s instructions should detect substance use.

• A urine test may give an indication of the drug / drugs the person has taken in the last 7 days but not the level of poisoning or intoxication.  If intoxication is confirmed, or continues to be suspected in a patient who has denied use, the nurse should aim to collect the following information:

• Type and amount of substance(s) used and by which route.

• Time frame for use, for example, all at once, over a specific time period, last ingestion/injection.

• If not known, the patient’s relevant medical history including alcohol and/or substance abuse. Information may need to be gathered from other services/agencies.

• Prescribed and non-prescribed medication used by the patient including amounts taken.

Management of Drug Overdose (Intoxication)

a.    The primary goal in the management of confirmed drug intoxication (or suspected drug use in cases where no other cause for the patient’s presentation has been found) is to ensure the patient’s safety whilst the effect of the drug remains in the body.

b.    The level of drug intoxication is on a continuum from mild to life threatening

The nurse must always be vigilant of the fact that the level of intoxication may continue to rise after cessation of use (for a specific time frame based on the substance(s) taken and when last taken). Therefore monitoring will be required over a period of time.

 c.    For patient who presents with complications of intoxication, for example, trauma, marked perceptual distortion, altered states of consciousness and/or an acute confusion:

• Specific attention must be given to consciousness levels and it is vital that this is assessed accurately as a decreased level of consciousness can occur in intoxication.

• Monitoring should be carried out half hourly initially and then hourly until it is confirmed by clinical judgment.

• Where there is presence of potential increased risk factors associated with illicit drug use, extra vigilance is required. For example, patients who have injected themselves with substances such as heroin (the injecting of a drug makes it most pharmacologically accessible and hence an increased risk).

• Where there is a history of using illicit drugs and prescribed concurrent drugs that depress the central nervous system. For example, methadone, benzodiazepines. Benzodiazepines can cause respiratory depression and this effect can be increased when combined with drugs of abuse.

d.    If it is deemed a medical emergency, for example, cardiac arrest, then institutional emergency procedures must be initiated immediately.

Management of Drug Abuse

The primary goals of drug-abuse or addiction treatment (also called recovery) are abstinence, relapse prevention, and rehabilitation. During the initial stage of abstinence, an individual who suffers from drug or chemical dependency may need help avoiding or lessening the effects of withdrawal. This process is called detoxification or ‘detox.’ That aspect of treatment is usually performed in a hospital or other inpatient setting, where medications used to lessen withdrawal symptoms and frequent medical monitoring can be provided. The medications used for detoxification are determined by the substance the individual is dependent upon. For example, people with alcohol dependence might receive medications like anti-anxiety (benzodiazepines) or blood pressure medications to decrease palpitations and blood pressure, or seizure medications to prevent possible seizures during the detoxification process.

For many drugs of abuse, the detoxification process is the most difficult aspect of coping with the physical symptoms of addiction and tends to last anywhere from a few days to a few weeks. Medications that are sometimes used to help addicted individuals abstain from drug use long term also depend on the specific drug of addiction. For example, individuals who are addicted to narcotics like Percodan (a combination of aspirin and oxycodone hydrochloride, heroin or Vicodin) often benefit from receiving longer-acting, less addictive narcotic-like substances like methadone (methadose).  People with alcohol addiction might try to avoid alcohol intake by taking disulfiram (Antabuse), which produces nausea, stomach cramping, and vomiting when the individual consumes alcohol.

Psychological addiction is often more challenging and time consuming than recovery from the physical aspects of addiction. For people who may have less severe drug dependency, the symptoms of psychological addiction may be managed in an outpatient treatment program. However, those who have a more severe addiction, have relapsed after participation in outpatient programs, or who also suffer from a severe mental illness might need the higher structure, support, and monitoring provided in an inpatient drug treatment rehabilitation centre. Following inpatient treatment, many people with this level of addiction can benefit from living in a sober living community, that is, a group-home setting where counsellors provide continued sobriety support and structure on a daily basis.

Another important approach in the treatment of addiction is helping the parents, other family members, and friends of the addicted person refrain from supporting addictive behaviours (co-dependency). Whether providing financial support, making excuses or failing to acknowledge the addictive behaviours of the addict, discouraging such co-dependency of loved ones is a key component to the recovery of the affected individual. A focus on the addicted person's role in the family becomes perhaps even more acute when that person is a child or teenager, given that minors exist within the context of a family in nearly every instance.

Complications of Drug Addiction

Drug addiction puts its sufferers at risk for potentially grave social, occupational, and medical complications. Drug addiction increases the risk of domestic violence in families. Individuals with chemical dependency are also much more likely to lose their job and less likely to find a job compared to people who are not drug addicted. Children of drug-addicted parents are at higher risk for poor social, educational, and health functioning, as well as being at higher risk for abusing drugs themselves.

In addition to the many devastating social and occupational complications of drug addiction, there are many medical complications of chemical dependency. From the respiratory arrest associated with heroin or sedative overdose to the heart attack or stroke that can be caused by cocaine or amphetamine intoxication.

7. Delirium

Delirium is a sudden change in a person’s mental function, which includes their ways of thinking and their behaviour or level of consciousness. This change often affects memory and concentration.

Causes of Delirium

Delirium is not always related to an underlying condition. It may be caused by:

• • Fever

  • Intoxication

  • Certain medications

  • Sleep deprivation

  • Emotional distress

Types of Delirium

The three types of delirium are:

• Hypoactive delirium: people may feel tired or depressed or move slower than normal.

• Hyperactive delirium: people may feel restless, agitated, or aggressive.

• Mixed delirium: people alternate between hypoactive and hyperactive states.

Management of Delirium

The ultimate goal in the management of delirium is to identify and appropriately manage any treatable or reversible causes for delirium. Supplemental oxygen, antidote administration, and antibiotic therapy are examples of interventions the emergency physician may use to manage delirium in the appropriate clinical context.

 8. Severe Depression

Depression was covered in the first module of Psychiatry and Mental Health Nursing course. In this section, we will discuss severe depression as a psychiatric emergency.

As a reminder to you, depression is defined as a state of low mood and loss of interest in most normally interesting activities that can affect a person's thoughts, behaviour, feelings and sense of well-being. Depressed people may feel sad, anxious, empty, hopeless, worried, helpless, worthless, guilty, irritable, hurt, or restless.

Apart from presenting as suicide/suicide attempt and or agitation, severely depressed patients may come to the emergency unit because of refusal to eat and drink, leading to dehydration which in turn may lead to physical illness or death. Therefore, severely depressed patients are sometimes considered to be part of psychiatric emergencies.

Management of Severe Depression as a Psychiatric Emergency

Suicide Ideation

In order to have understanding of the management of severely depressed patients with suicidal ideas, you are requested to revisit the notes on suicide attempts under section 2.4.

Patient in a Depressive Stupor

In an emergency situation, the general aspect of the patient’s symptomatology is not the main focus of the care, but worry about the patient starving or being dehydrated to death because of their refusal to eat or drink. In this regard, nursing care will focus on interventions that will encourage the patient to eat and drink such as persuasion of the patient through a well-established nurse-patient relationship or giving fluids through intravenous line in extremely weak patients. The idea is to replace fluids and boost energy levels in the patient.

9. Iatrogenic Emergencies

In psychiatry, iatrogenesis can occur due to misdiagnosis (including diagnosis with a false condition, as was the case of hystero-epilepsy). An example of a partially iatrogenic condition due to common misdiagnosis is bipolar disorder, especially in pediatric patients. Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence. Adverse reactions, such as allergic reactions to drugs, even when unexpected by pharmacotherapists, are classified as iatrogenic.

A. Psychiatric Complications of Drugs used in Medicine

Side effects of drugs are unwanted effects that occur after a drug is consumed at the right dose. These side effects can be expected, and may bring benefits or harm towards the patient. Drug side effects occur depending on how the drug acts on the body or depending on its mechanism of action. Common drug side effects include nausea, vomiting, dizziness and abdominal pain. However, there are also drugs that cause confusion as one of its side effects.

Confusion as a Drug Side Effect

How does confusion as a drug side effects occur?

Confusion is one of the side effects caused by medications. This is particularly caused by medications that can prevent the transmission of signals between cells by acetylcholine. Acetylcholine is an organic chemical contained in the human body that acts as a neurotransmitter (a chemical secreted by nerve cells to send signals to the other cells of the body). This effect is also known as anticholinergic effect.  For example, first-generation antihistamines are known to cause confusion as its side effects. The main mechanism of action of first-generation antihistamine is on the H1 receptors. The drugs act by competing with histamine for binding site at H1 receptors, eventually inhibiting the action of histamine, and exerting its intended clinical effects. In addition, the first generation antihistamine drugs can also inhibit the action of acetylcholine on muscarinic receptors due to their ability to cross the blood brain barrier and also due to the similarity of its chemical structure when compared to acetylcholine. This leads to side effects such as confusion, even when the drug is taken at therapeutic dose.

Who is at risk of confusion as a side effect?

In extreme states, confusion may progress into delirium. Research shows that elderly patients are more prone to side effects related to muscarinic receptor inhibition. This effect is caused by three factors:

• First, the body’s ability to eliminate the drug wears off with age, this is due to the reduction in kidney and liver function with aging.

• Second, the elderly often takes a variety of medications because they often suffer from various diseases at the same time. The interaction between the drugs causes side effects to occur more easily.

• The third factor is a reduction in the amount of acetylcholine in the body as the body ages.

Which medicines can cause confusion as a side effect?

As stated before these include:

• First generation antihistamines, which are known to cause confusion. For example diphenhydramine and promethazine. These antihistamines are used to treat symptoms such as coughs or to treat allergy symptoms such as itchiness. 

• Painkillers that belong to the opioid group can also cause confusion as one of its side effects. Examples of painkillers under this group are Morphine, Fentanyl, Codeine phosphate and Oxycodone.

• Anticholinergic agents such as Procyclidine HCl used in the treatment of Parkinson’s disease may also results in confusion.

• Benzodiazepines such as Clonazepam, which is commonly used to treat epilepsy, as well as tricyclic antidepressants such as Amitriptyline, can cause similar side effects in some patients.

What actions should be taken if a patient experiences confusion as a drug side effect?

If the patient experiences confusion after taking a prescribed drug and the symptoms do not disappear and interfere with daily life, advice the patients to inform the doctor or pharmacist. You should also advice the patient to continue taking the medication prescribed by the doctor unless informed by the doctor to stop. 

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