Psychiatric emergency

Manoe Bernd P., dr., SpKJ., Mkes

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Gawat darurat jiwa

life threatening:
Intoxikasi
Percobaan bunuh diri
Urgent Melukai diri/ orang lain
Dellirium ec KMU
Neuroleptic Malignant Syndrome
Emergency

Tidak mengancam nyawa

Sindroma Putus Zat

Non Urgent

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 Strategi mengevaluasi pasien GD
Jiwa
Self
SelfProtection
Protection
1 Kenali px sedalam mungkin, sebelum bertemu langsung
2 Serahkan fiksasi pada yang terlatih
3 Selalus siaga terhadap kemungkinan tindak kekerasan
4
Selalu tersedia akses keluar
5 Melakukan pemeriksaan tidak seorang diri

6 Membangun hubungan yang nyaman dgn px (tidak konfrontasi)

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Strategi mengevaluasi pasien GD

Jiwa continu..
Cegah
Cegahkekerasan
kekerasan

Prevent
Preventself-
self-injury and
self-injury andsuicide
suicide
Gunakan cara apapun
Gunakan cara apapun

Mencegah terjadinya kekerasan:

1. Informasikan ke px, tentang tindak kekerasan.

2. Dekati pasien dengan pendekatan persuasif (nyaman).
3. Tenangkan px & uji daya pikir realita.
4. Tawarkan pengobatan.
5. Informasikan jika fiksasi mungkin dilakukan jika diperlukan
6. Tim untuk fiksasi selalu siap ditempat.
7. Saat pasien menjalani fiksasi, selalu awasi dengan ketat
8. Periksa rutin Tanda Vital
9. Cegah px dari paparan2x yg mengakibatkan agitasi
10.Segera siapkan pendekatan berikutnya (pengobatan/evaluasi terapi)
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Ciri ggn jiwa akibat Kondisi Medik
Umum
1 Onset
Onset Akut
Akut (Jam/
(Jam/ Menit)
Menit)

2 Pertama
Pertama kali
kali sakit (1stst episode)
sakit (1 episode)
3 Usia
Usia Tua
Tua

4 Riwayat
Riwayat sakit
sakit medis
medis saat
saat ini/
ini/ Trauma
Trauma

5 Riwayat
Riwayat Penyalahgunaan
Penyalahgunaan zat
zat (nyata
(nyata saat
saat ini)
ini)

6 Ggn
Ggn Persepsi
Persepsi (-)
(-) t.u
t.u halusinasi
halusinasi dengar
dengar

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Ciri ggn jiwa akibat Kondisi Medik

Umum continu..
7 Gejala-gejala
Gejala-gejala Neurologis
Neurologis

Penurunan
Penurunankesadaran
kesadaran

Kejang
Kejang

Trauma
TraumaKepala
Kepala

Nyeri
Nyerikepala
kepalaberat
berat

Perurunan
Perurunanvisus
visus

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 Ciri ggn jiwa akibat Kondisi Medik
Umum continu..
8 Gejala-gejala
Gejala-gejala Neurologis
Neurologis Klasik
Klasik

Ggn
Ggnperhatian
perhatian&&Konsentrasi
Konsentrasi
Disorientasi
Disorientasi
Gangguan
GangguanMemory
Memory
dyscalculia
dyscalculia
9 Tanda
Tanda status
status mental
mental lainnya
lainnya

Bicara/
Bicara/gangguan
gangguanGerakan
Gerakan

Constructional
Constructionalapraxia:
apraxia:
Gambar
GambarJam.
Jam.Pentagonal
Pentagonalberpotongan
berpotongan
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Syndrome Emergency Manifestations Treatment Issues

Abuse of child or Signs of physical trauma
adult
Acquired immune Changes in behavior secondary to
deficiency organic causes; changes in
syndrome behavior secondary to fear and
(AIDS) anxiety; suicidal behavior
Adolescent crises Suicidal attempts and ideation;
substance abuse, truancy, trouble
with law, pregnancy, running
away; eating disorders; psychosis
Agoraphobia Panic; depression
Management of medical problems;
psychiatric evaluation; report to
authorities
Management of neurological illness;
management of psychological
concomitants; reinforcement of
social support
Evaluation of suicidal potential, extent
of substance abuse, family
dynamics; crisis-oriented family
and individual therapy;
hospitalization if necessary;
consultation with appropriate
extrafamilial authorities
Alprazolam (Xanax), 0.25 mg to 2 mg;
propranolol (Inderal);
antidepressant medication

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Alcohol-related emergencies
Alcohol delirium Confusion, disorientation, fluctuating Chlordiazepoxide (Librium);
consciousness and perception, haloperidol (Haldol) for psychotic
autonomic hyperactivity; may be symptoms may be added if
fatal necessary
Alcohol Disinhibited behavior, sedation at high With time and protective environment,
intoxication doses symptoms abate
Alcohol psychotic Vivid auditory (fat times visual) Haloperidol for psychotic symptoms
disorder with hallucinations with affect
hallucinations appropriate to content (often
fearful); clear sensorium
Alcohol seizures Grand mal seizures; rarely status Diazepam (Valium), phenytoin
epilepticus (Dilantin); prevent by using
chlordiazepoxide (Librium) during
detoxification
Alcohol Irritability, nausea, vomiting, insomnia, Fluid and electrolytes maintained;
withdrawal malaise, autonomic hyperactivity, sedation with benzodiazepines;
shakiness restraints; monitoring of vital
signs; 100 mg thiamine IM
Korsakoff's Alcohol stigmata, amnesia, No effective treatment;
syndrome confabulation institutionalization often needed
Wernicke's Oculomotor disturbances, cerebellar Thiamine, 100 mg IV or IM, with
encephalopathy ataxia; mental confusion MgSO4 given before glucose
loading

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Delirium Fluctuating sensorium; suicidal and Evaluate all potential contributing factors
homicidal risk; cognitive clouding; and treat each accordingly;
visual, tactile, and auditory reassurance, structure, clues to
hallucinations; paranoia orientation; benzodiazepines and low-
dosage, high-potency antipsychotics
must be used with extreme care
because of their potential to act
paradoxically and increase agitation
Delusion Most often brought in to emergency room Antipsychotics if patient will comply (IM if
al involuntarily; threats directed toward necessary); intensive family
disor others intervention; hospitalization if necessary
der
Dementi Unable to care for self; violent outbursts; Small dosages of high-potency
a psychosis; depression and suicidal antipsychotics; clues to orientation;
ideation; confusion organic evaluation, including medication
use; family intervention
Depressi Suicidal ideation and attempts; self-neglect; Assessment of danger to self;
ve substance abuse hospitalization if necessary,
disor nonpsychiatric causes of depression
ders must be evaluated

Neuroleptic Hyperthermia; muscle rigidity; autonomic Discontinue antipsychotic; IV dantrolene

malignant instability; parkinsonian symptoms; (Dantrium); bromocriptine (Parlodel)
syndrome catatonic stupor; neurological signs; orally; hydration and cooling; monitor
10% to 30% fatality; elevated CPK levels
creatine phosphokinase

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 Terapi di EMG
• Penting !! Inform Consent
• Farmakoterapi
– Evaluasi berdasarkan kondisi EMG jiwa saat ini
• Restraint (fiksasi)

1. Preferably five or a minimum of four persons should be used to restrain the patient. Leather
restraints are the safest and surest type of restraint.
2. Explain to the patient why he or she is going into restraints.
3. A staff member should always be visible and reassuring the patient who is being restrained.
4. Reassurance helps alleviate the patient's fear of helplessness, impotence, and loss of
control.
5. Patients should be restrained with legs spread-eagled and one arm restrained to one side
and the other arm restrained over the patient's head.
6. Restraints should be placed so that intravenous fluids can be given, if necessary.
7. The patient's head is raised slightly to decrease the patient's feelings of vulnerability and to
reduce the possibility of aspiration.
8. The restraints should be checked periodically for safety and comfort.
9. After the patient is in restraints, the clinician begins treatment, using verbal intervention.
10. Even in restraints, most patients still take antipsychotic medication in concentrated form.
11. After the patient is under control, one restraint at a time should be removed at 5-minute
intervals until the patient has only two restraints on. Both of the remaining restraints should
be removed at the same time, because it is inadvisable to keep a patient in only one
restraint.
12. Always thoroughly document the reason for the restraints, the course of treatment, and the
patient's response to treatment while in restraints.
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The Best Predictors of

Potential Violence Behavior.

1. Excessive alcohol and other

substance intake.
2. A History of Violent acts with arrest
or criminal activity.
3. A History of Childhood abuse.

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 Treatment
Manage the Potentially Violent patient .
Avoids :  Threats
 Disagreement .
 Unrealistic Promises
 No Levity .
 NO Staring
 Avoid unnecessary drug.
 Be Alert for Physical disorders.
Patients must be placed in safe setting.
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Assessing and predicting violence

behavior :
1. Sign of impending violence.
2. Psychomotor Agitation.
4. Paranoid features.
6. Brain diseases.
8. Manic Episodes.
• Recent acts of violence .
• Verbal / physical threats.
• Carrying weapon .
3. Substances intoxication .
5. Command hallucination
7. Catatonic Excitement
9. Personality disorders.

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Assess the Risk for Violance
1. Consider Viol Ideation .
2. Male ( age 15 - 41 )
3. Socioeconomic ( low )
4. Social support ( few )
5. Consider overt stress
6. Consider : • impuls dyscontrol • gambling
• substance abuse • self injury
• psychosis • history violence
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 Some need to transferred to forensic

unit
 medication specific is administrated
when indicated .
 Medication is contra indication in
acutely agitated who have suffered
a head injury because medication
can confuse the clinical picture

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general i.m. Haloperidol is one of most
useful emergency treatments for violent
psychotic patient .

ECT. Had also been used in emergencies to

control Psychotic violence .
 Psychotherapy
 Pharmacotherapy
 Rapid tranquilization

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Suicide

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 Suicide
Suicide is intentional self inflected death .
Edwin Schneidman
Suicide  the conscious act of self induced
anihilation

Epidemiology
Successful suicide each year about 30.000 .
30.232 death in 1989 .
The number of attempted suicides 8 -- 10
times that number.
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reporting misclassifications of the cause of

death :
Accident (undetermined)
Chronic suicide
Death through substance
Diabetes
Obesity
Hypertension

Suicide is ranked as the eight over all cause of death

after heart diseases, cancer , CVD, Accident,
Pneumonia, diabetes beme_psy@yahoo,com
and Cirrhosis .
 Evaluation of suicide Risk
Demographic and social profile .

 Age 15 to 24
 Sex male
 Marital divorce / widowed

 Employment unemployment

Female > risk suicide attempt age 15-25

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Interpersonal relationship Conflicts

Family back ground Chaostic
Conflictual
Health physical
chronic illness
Hypochondriac
substance intake

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Mental
 Severe depression
 psychosis
 severe personality
 disorders
 substance abuse
 hopelessness

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Suicidal Activity
1. Suicidal ideation
frequent
intense
prolong

2. Suicidal Attempt
Multiple Attempt
planned

rescue unlike

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 Communication internalized
( self blame )

Resources
1. Personal
poor achievement
poor insight

2. Social
poor rapport
social isolated

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Suicidal ideation treatment

• Hospitalisasi jika :
– abscense strong social support system
– History of impulsive behavior
– Suicidal plan of action
• If refuse hospitalization ; familly have to responsible 24
hours a day
• Oral medication :
– Antidepressant
– Antipsychotic
– Or both
• Psychotherapy ; individual supportive psychotherapy

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 Terimakasih

http://www.psikiatrirsudjayapura.wordpress.com

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