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Psychiatric emergencies are acute changes in behavior that negatively impact a patient's ability to function in his or her environment. Often such patients are in a state of crisis in which their baseline coping mechanisms have been overwhelmed by real or perceived circumstances. In dealing with such emergencies, the emergency physician faces many challenges and must prioritize his or her clinical efforts toward four main concerns.

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First, the physician must ensure his or her own safety and the patient's well-being if violence or agitated behavior is present. Second, the physician must perform an effective screening assessment, probing for organic causes and completing a psychiatric safety check. The screening assessment ensures that there is no underlying medical cause for the patient's condition, either initially inducing the aberrant behavior or evolving as a consequence of that behavior (eg, malnutrition or dehydration). The screening assessment also involves a psychiatric safety check to explore for suicidal ideation, homicidal ideation, or patients' inability to care for themselves. Third, the physician must ensure that the patient receives appropriate psychological support and medical treatment, even if the treatment needs to be provided without the patient's consent. Lastly, the physician must determine the appropriate disposition for the patient.

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The algorithm in Figure 49–1 provides a decision-making guide to the management of psychiatric emergencies. This algorithm reflects the four main priorities in patient care and provides a framework for this chapter.

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Figure 49–1.
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Decision-making algorithm for psychiatric emergencies.

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1This chapter is a revision of the chapter by Gregory Hall, MD and Denis J. FitzGerald, MD from the 6th edition.

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The emergency physician may encounter patient who threatens or exhibits violent behavior toward staff. In these cases, it is important to recognize the early warning signs of impending violence and adopt an approach to management that reduces the likelihood of injury to staff and patient. Early warning signs of impending violence include threatening statements, clenched fists, loud vocalizations, shifting body positions toward a fighting posture, agitated movements, and striking inanimate objects. If such behavior is detected, adopt the S.A.F.E.S.T. approach:

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  • Spacing—Maintain distance from the patient. Allow both the patient and you to have equal access to the door. Do not touch a violent person.
  • Appearance—Maintain empathetic professional detachment. Use one primary contact person to build rapport. Have security staff available as a show of strength.
  • Focus—Watch the patient's hands. Watch for potential weapons. Watch for escalating agitation.
  • Exchange—Delay by calm, continuous talking is crucial to permit de-escalation of the situation. Avoid punitive or judgmental statements. Use good listening skills. Target the current problem or situation in order to find face-saving alternatives for resolution and to elicit the patient's cooperation with treatment.
  • Stabilization—If necessary, use three stabilization techniques to get control of the situation: physical restraint, sedation, and chemical restraint. ...

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