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Kegawatdaruratan Jiwa

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
Kenali px
px sedalam
sedalam mungkin,
mungkin, sebelum
sebelum bertemu
bertemu langsung
langsung
2 Serahkan
Serahkan fiksasi
fiksasi pada
pada yang
yang terlatih
terlatih
3 Selalus
Selalus siaga
siaga terhadap
terhadap kemungkinan
kemungkinan tindak
tindak kekerasan
kekerasan
4
Selalu
Selalu tersedia
tersedia akses
akses keluar
keluar
5 Melakukan
Melakukan pemeriksaan
pemeriksaan tidak
tidak seorang
seorang diri
diri

6 Membangun
Membangun hubungan
hubungan yang
yang nyaman
nyaman dgn
dgn px
px (tidak
(tidak konfrontasi)
konfrontasi)

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Strategi mengevaluasi pasien GD
Jiwa continu..
Cegah
Cegahkekerasan
kekerasan

Prevent
Preventself -injury and
self-injury andsuicide
suicide
Gunakan
Gunakancara
caraapapun
apapun

Mencegah
Mencegahterjadinya
terjadinyakekerasan :
kekerasan:

1.
1. Informasikan
Informasikanke kepx,
px,tentang
tentangtindak
tindakkekerasan.
kekerasan.
2.
2. Dekati
Dekatipasien
pasiendengan
denganpendekatan
pendekatanpersuasif
persuasif(nyaman).
(nyaman).
3.
3. Tenangkan
Tenangkanpx px&&ujiujidaya
dayapikir
pikirrealita.
realita.
4.
4. Tawarkan
Tawarkanpengobatan.
pengobatan.
5.
5. Informasikan
Informasikanjikajikafiksasi
fiksasimungkin
mungkindilakukan
dilakukanjika
jikadiperlukan
diperlukan
6.
6. Tim
Timuntuk
untukfiksasi
fiksasiselalu
selalusiap
siapditempat.
ditempat.
7.
7. Saat
Saatpasien
pasienmenjalani
menjalanifiksasi,
fiksasi,selalu
selaluawasi
awasidengan
denganketat
ketat
8.
8. Periksa
Periksarutin
rutinTanda
TandaVitalVital
9.
9. Cegah
Cegahpx pxdari
daripaparan2x
paparan2xyg ygmengakibatkan
mengakibatkanagitasi
agitasi
10.
10.Segera
Segerasiapkan
siapkanpendekatan berikutnya
berikutnya(pengobatan/evaluasi
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pendekatan (pengobatan/evaluasiterapi)
terapi)
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 Management of medical problems;
adult psychiatric evaluation; report to
authorities
Acquired immune Changes in behavior secondary to Management of neurological illness;
deficiency organic causes; changes in management of psychological
syndrome behavior secondary to fear and concomitants; reinforcement of
(AIDS) anxiety; suicidal behavior social support
Adolescent crises Suicidal attempts and ideation; Evaluation of suicidal potential, extent
substance abuse, truancy, trouble of substance abuse, family
with law, pregnancy, running dynamics; crisis-oriented family
away; eating disorders; psychosis and individual therapy;
hospitalization if necessary;
consultation with appropriate
extrafamilial authorities
Agoraphobia Panic; depression 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 homicidal risk; Evaluate all potential contributing factors and treat
cognitive clouding; visual, tactile, and auditory each accordingly; reassurance, structure,
hallucinations; paranoia clues to orientation; benzodiazepines and low-
dosage, high-potency antipsychotics must be
used with extreme care because of their
potential to act paradoxically and increase
agitation

Delusional Most often brought in to emergency room Antipsychotics if patient will comply (IM if
disord involuntarily; threats directed toward others necessary); intensive family intervention;
er hospitalization if necessary

Dementia Unable to care for self; violent outbursts; psychosis; Small dosages of high-potency antipsychotics;
depression and suicidal ideation; confusion clues to orientation; organic evaluation,
including medication use; family intervention

Depressiv Suicidal ideation and attempts; self-neglect; Assessment of danger to self; hospitalization if
e substance abuse necessary, nonpsychiatric causes of
disord depression must be evaluated
ers

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


malignant instability; parkinsonian symptoms; (Dantrium); bromocriptine (Parlodel) orally;
syndrome catatonic stupor; neurological signs; 10% to hydration and cooling; monitor CPK levels
30% fatality; elevated 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. Recent acts of violence .
Verbal / physical threats.
Carrying weapon .
2. Psychomotor Agitation. 3. Substances intoxication .
4. Paranoid features. 5. Command hallucination
6. Brain diseases. 7. Catatonic Excitement
8. Manic Episodes. 9. Personality disorders.

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Assess the Risk for Violance
1. Consider Viol Ideation .
2. Male ( age 15 - 14 )
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
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 and Cirrhosis .
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Evaluation of suicide Risk
Demographic and social profile .

Age over 45 years


Sex male
Marital divorce / widowed

Employment unemployment

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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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Terimakasih

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