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
SSeelflfPProrotet
ecctitoionn

1 Kenali px sedalam mungkin,

sebelum bertemu langsung
3
2 Serahkan fiksasi pada
3
yang terlatih
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..
CCeeggaahhkkeekk
eerarassaann
Prevent self-injury and suicide
Prevent self-injury and 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 pendebke
Ciri ggn jiwa akibat Kondisi Medik
Umum
1 Onset
Onset Akut
Akut (Jam/
(Jam/ Menit)
Menit)

2 Pertama kali
Pertama kali sakit
sakit (1
(1stst episode)
episode)

3 Usia Tua
Usia Tua

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

5 Riwayat Penyalahgunaan
Riwayat Penyalahgunaan zat zat (nyata
(nyata saat
saat ini)
ini)
6 Ggn Persepsi
Ggn Persepsi (-)
(-) t.u
t.u halusinasi
halusinasi dengar
dengar

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Ciri ggn jiwa akibat Kondisi Medik

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

Penurunan kesadaran
Penurunan kesadaran
Kejang Trauma
Kejang
Kepala Nyeri
Trauma Kepala
kepala berat
Nyeri kepala berat
Perurunan visus
Perurunan visus

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

Ggn perhatian & Konsentrasi

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

Bicara/
Bicara/gangguan
gangguanGerakan
Gerakan

Constructional apraxia:apraxia:
Constructional Gambar Jam.
Pentagonal
Gambar berpotongan
Jam. Pentagonal
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
W ernicke'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

2. restraints
Explain toare
the the safest
patient and
why hesurest
or shetype of restraint.
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. should be restrained with legs spread-eagled and one arm restrained to one side
5. Patients
and the other
6. Restraints arm be
should restrained over
placed so the
that patient's head.
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
8. The the possibility
restraints of aspiration.
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
be removeduntil
atthe
thepatient has only
same time, two restraints
because on. Both
it is inadvisable toof the a
keep remaining
patient inrestraints
only one should

12. restraint.
Always thoroughly document the reason for the restraints, the course of treatment, and
the patient's response to treatme
nt 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. beme_psy@yahoo,com

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

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