Psychiatric emergency

    1. Psychiatric emergency
  • 🌱epidemiology:

– sex = equal

– time = night hours

– marital status = single (more common)

– presentation:

*20% suicidal

*10% violent or agitation

– diagnosis = mood disorder, schizophrenia and alcohol abuse

– hospitalizations = needed in 40% of cases



🌱Psychiatric emergency presentation

1- agitation

2- suicidal & deliberate self herm

3- LOC

4- substance misuse & dependency

5- Refusal to take food

6- catatonic immobility (waxy flexibility, the most easy type of schizophrenia )

7- panic attack

8- somatoform disorder

9- factitious disorder

10 – Side effects of medications, particularly Antipsychotics

11- Any Psychiatric Disorder may present to emergency room!!!





🌱Agitation :



— anxiety-> apprehension feeling caused by anticipation (expectation) of danger (internal or external danger)


— fear -> anxiety cause by consciously recognized and realistic dangerous


— tension -> increased and unpleasant motor and psychological activity


— agitation -> The subjective feeling of being upset, angry, disturbed, or unable to rest.


— aggression -> Destructive or punitive behavior directed toward people or objects.


— Violence -> aggressive behavior that transgresses social norms.


** E.g. – boxing is an aggression, but street fighting is violence.


management in emergency room:-


1- protect your self & never confront the patient

2- think about the possible cause of agitation

3- calm the patient verbally

4- offer help and agreement, offer food,…

5- medication

*oral -> if refuse -> parental

*benzodiapepime groups

*anti-psychotic (Haloperidol 5-10mgs, Olanzapine 5-10mgs)

6- follow chart (Check vital signs each 5 minutes for the first hour and then half hourly until the patient become ambulant.)

7- restraint

8- call senior or specialist on call.





🌱 Extra pyramidal Side Effects (EPS) in the emergence:


* EPS include the following:


1. Neuroleptic Malignant Syndrome (NMS)


2. Acute Dystonia


3. Akathesia


4. Parkinsonism


5. Tardive Dyskinesia



* EPS occur after intake of:-

1-Antipsychotics (more with typical agents)

2- Antiemetic like metoclopramide.

3- Agents used for vertigo like Prochlorperazine (Stemitel).




1️⃣Neuroleptic malignant syndrome :


∆ Medical emergency, idiosyncratic reaction, may occurs even after single small sized dose


– more common in young male

– more common in early course of treatment

– may occur due to rapid increase in the doses of Antipsychotics.


∆ Rate: 0.02-2.4% of those who receive anti dopamines.


∆Mortality: 10-20%.



∆clinical features:

– elevated the temperature

– excessive sweating

– impaired the consciousness

– body rigidity

– autonomic disturbance (increased or decreased heart rate, or blood pressure.)



∆ Cause of death (complications)

– hypovolemic shock (due to excessive sweating) —> acute renal failure

– Myoglubinurea (due to muscle damage resulted from extreme rigidity —> renal failure

– Electrolyte disturbances.

– Aspiration (extreme muscle contractions and difficulty in swallowing)

– Respiratory failure.



∆  Investigations :

– increase WBCs

– elevated creatinine phosphokinase



∆  DDx

– Meningitis & Encephalitis

– Catatonic Schizophrenia.



∆  treatment

– stop the medication

– admission to ICU

– Check vital signs half an hourly + regular follow up.

– IV fluid

– Correct electrolyte disturbances (Na, K, Ca).

– Packing (to reduce the temperature)

– medication

* Benzodiazepine

* Bromocriptine (dopamine agonist) may be beneficial, start with small doses and increase gradually to maximum of 60 mgs /day.

* Dantroline (muscle relaxant) can be used up to 10 mgs/day, but in intensive care unit.

– call senior or specialist on call.


2️⃣ Acute dystonia



uncontrolled spasm and posturing of a group of muscles


– more common in male

– more common in early treatment (90% of case occur within first 5 days of starting medications)

– more with typical Antipsychotics, especially with Haloperidol, and Trifluperazine.


✓Clinical type

– Oculogyric crisis

*movement of the eye about the anteroposterior axis.

* Seen in children

– Blepharospasm

– Torticollis

– Opisthotonus

– Pleurothotonus

*tetanic bending of the body to one side.



– Consider reduction in the dosage or changing the Antipsychotic.


– Anticholinergics

*Benztropine 1-4mg/day,

*Procyclidine 5-15mgs/day,



– Antihistamine

* Diphenihydramine (allermin) (25-200mgs/day)


**diazepam may use






subjective feeling of restlessness



– beta blocker like propanol


– diazepam

**no benefit from anticholinergic







5️⃣Tardive dyskinesia



bucco-lingular movement = chewing movement = rabbit syndrome


** may also be choreoathetoid movements of the extremities


– female more than male

– elderly more than young


— caused by long-term use of antipsychotic drugs

* incidence is related to drug dosage and duration of treatment




– stop medication

– change to other antipsychotic like clozapine


** In some patients symptoms disappear within a few months after the drugs are withdrawn; in others symptoms may persist indefinitely.


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