Chapter 22 Psychiatric Emergencies

Transcription

1 1 Chapter 22 Psychiatric Emergencies Introduction EMTs often dea with patients undergoing psychoogica or behaviora crisis. Crisis might be the resut of: Acute medica situation Menta iness substances Stress Myth and Reaity At some point, most peope experience an emotiona crisis. Does not mean that everyone deveops menta iness Ony a sma percentage of menta heath patients are. Perfecty heathy peope may have symptoms occasionay. Defining Behaviora Crisis (1 of 3) Behavior: What you can see of a person s to the environment and his or her actions Behaviora crisis or Psychiatric Emergency: May invove patients who exhibit agitated, vioent, or uncooperative behavior or who are a danger to themseves or others. EMS is caed when behavior has become unacceptabe to patient, famiy, or community. Defining a Behaviora Crisis (2 of 3) If an abnorma pattern of behavior asts for at east a month, it is a matter of concern. Chronic depression is a feeing of sadness and despair. May be a symptom of a menta or physica disorder Defining a Behaviora Crisis (3 of 3) When a psychiatric emergency arises, the patient: May show agitation or vioence 1

2 When a psychiatric emergency arises, the patient: May show agitation or vioence May become a threat to or others The Magnitude of Menta Heath Disorders (1 of 4) Menta disorders are common throughout the United States, affecting tens of miions of peope each year. A psychiatric disorder is an iness with psychoogica or behaviora symptoms that may resut in impaired. The Magnitude of Menta Heath Disorders (2 of 4) Anxiety disorders: Generaized anxiety disorder Panic disorder Socia and other Posttraumatic stress disorder (PTSD) Obsessive compusive disorder The Magnitude of Menta Heath Disorders (3 of 4) The US menta heath system provides many eves of assistance. Most psychoogica disorders can be handed through visits. Some peope require hospitaization in speciaized psychiatric units. The Magnitude of Menta Heath Disorders (4 of 4) Psychiatric disorders have many underying causes: Socia and situationa stress such as divorce or death of a oved one Diseases such as Physica inesses such as diabetic emergencies Chemica probems such as acoho or drug use Bioogica disturbances such as eectroyte imbaances Pathophysioogy An EMT is not responsibe for diagnosing the underying cause of a behaviora crisis or psychiatric emergency. You shoud know the two basic categories of diagnosis a physician 2

3 behaviora crisis or psychiatric emergency. You shoud know the two basic categories of diagnosis a physician wi use: Functiona Organic Brain Syndrome A temporary or permanent dysfunction of the brain caused by a disturbance in the physica or physioogic functioning of the brain tissue. Causes may incude sudden iness, traumatic brain injury (TBI), seizure disorders, drug and acoho abuse,, withdrawa, and diseases of the brain Functiona Disorders A physioogica disorder that impairs bodiy functions when the body seems to be structuray norma. Exampes incude, anxiety conditions, and depression. There may be a chemica or physica cause, but it is not we understood. Safety Guideines Be prepared to spend extra time. Have a pan of action. Identify yoursef. Be. Be direct. Assess the scene. Stay with patient. Encourage purposefu movement. Express interest. Do not get too cose. Avoid fighting. Be honest and reassuring. Do not. Scene Size-Up Scene 3

4 Scene Is the situation unduy dangerous to you and your partner? Do you need immediate aw enforcement backup? Does the patient s behavior seem typica or norma for the circumstances? Are there ega issues invoved? Primary Assessment ABCs Avoid the patient without permission Be prepared for changes in patient s behavior History Taking Consider three major areas: Is the patient s functioning propery? Are haucinogens, other drugs, or acoho a factor? Are psychogenic circumstances, symptoms, or an iness invoved? SAMPLE history Secondary Assessment (1 of 2) Physica Exam: A conscious patient may not respond at a to your questions. Obtain vita signs when doing so wi not exacerbate the patient s emotiona distress. Make every effort to assess bood pressure, puse, respirations, skin, and pupis Secondary Assessment (2 of 2) Transport decision Have aw enforcement or firefighters you if possibe. Take the patient to a faciity capabe of caring for patients with psychiatric probems. Transport the patient by ground. 4

5 20 Reassessment (1 of 3) Never et your guard down. Many patients wi act. If restraints are necessary, reassess and document every 5 minutes: Respirations Puse and motor and sensory function in a restrained extremities Reassessment (2 of 3) Interventions and contro the situation. Intervene ony as much as it takes to accompish these tasks. If you think a pharmacoogic restraint is necessary, request ALS assistance as eary as possibe Reassessment (3 of 3) Communication and documentation Give the receiving hospita advance of the psychiatric emergency. Document thoroughy and carefuy. If restraints are used, identify which types and why they were used. Acute Psychosis Psychosis is a state of deusion in which the person is out of touch with. Affected peope ive in their own reaity of ideas and feeings Schizophrenia (1 of 2) A compex disorder that is not easiy defined or treated. Typica onset occurs during. Infuences thought to contribute incude: Brain damage Genetics Psychoogica and socia infuences Schizophrenia (2 of 2) Persons with schizophrenia experience symptoms incuding: 5

6 Persons with schizophrenia experience symptoms incuding: Deusions A ack of interest in peasure Erratic speech Guideines for Deaing With a Psychotic Patient Determine if the situation is dangerous. Identify yoursef ceary. Be cam, direct, and straightforward. Maintain an emotiona distance. Do not. Expain what you woud ike to do. Invove peope the patient trusts, such as famiy or friends, to gain patient cooperation. Excited Deirium Deirium is a condition of impairment in cognitive function that can present with disorientation, haucinations, or deusions. : behavior characterized by restess and irreguar physica activity. Patients may strike out irrationay. Your persona safety must be considered. S/S of Excited Deirium (1 of 2) Hyperactive irrationa behavior Vivid haucinations Hypertension Diaphoresis Diated pupis S/S of Excited Deirium (2 of 2) Be cam, supportive, and empathetic. Approach the patient sowy and purposefuy and respect the patient s territory. Limit physica contact. Do not eave the patient. 6

7 Do not eave the patient. Deaing With Excited Deirium (1 of 2) Try to indirecty determine the patient s: Memory Concentration Judgment Pay attention to the patient s abiity to communicate, appearance, dress, and persona hygiene. Deaing With Excited Deirium (2 of 2) If you determine the patient requires restraint, make sure you have adequate personne avaiabe to hep you or request ALS assistance so restraint can be considered. If the patient has overdosed, take a medication bottes or iega substances to the medica faciity. Refrain from using ights and sirens. Restraint (1 of 8) Every prehospita care transport provider shoud create and foow a prehospita patient restraint protoco. Protocos vary widey. The restraint chosen shoud be the east restrictive option that ensures the of the patient and providers. Restraint (2 of 8) Personne must be propery trained. If you restrain a person without authority in a nonemergency situation, you expose yoursef to a possibe awsuit. Lega actions can invove charges of assaut,, fase imprisonment, and vioation of civi rights. Restraint (3 of 8) You may use restraints ony: To protect or others from bodiy harm 7

8 You may use restraints ony: To protect or others from bodiy harm To prevent the patient from injuring himsef or hersef Restraint (4 of 8) Invove aw enforcement if the patient is in a severe behaviora crisis or psychiatric emergency. Before considering physica restraint, use verba techniques. Make sure restraints do not restrict dista circuation Do not reease unti arriva at ER Restraint (5 of 8) Process of restraining a patient Carry out the decision quicky. There shoud be 5 peope to hep, one responsibe for each and one responsibe for the head. There shoud be a team eader and pan of action. Use the minimum force necessary. Restraint (6 of 8) The eve of force wi vary, depending on these factors: The degree of force that is necessary to keep the patient from injuring sef and others The patient s sex, size, strength, and menta status The type of behavior the patient is exhibiting Restraint (7 of 8) Tak to the patient throughout the process. Treat the patient with dignity and. If possibe, a provider of the same gender shoud attend to the patient. Wear appropriate barrier protection. 8

9 Restraint (8 of 8) Avoid direct eye contact and respect persona space. Never eave a restrained person. Four-point restraints (both arms and both egs) are preferred. Monitor the patient cosey. Use Soft Restraints Monitor Dista Circuation Suicide (1 of 5) Suicide (2 of 5) Suicide (3 of 5) Suicide (4 of 5) Suicide (5 of 5) Geriatric Needs Depression is a common menta status probem. Dementia is a change in menta status. Underying conditions may cause atered behavior. A smie and a touch can go a ong way in aeviating fear, especiay with the edery. Posttraumatic Stress Disorder and Returning Combat Veterans (1 of 6) PTSD occurs after exposure to, or injury from, a traumatic event. An estimated 7% to 8% of the genera popuation wi experience PTSD at some point in their ives. Miitary personne with combat experience have a incidence. Posttraumatic Stress Disorder and Returning Combat Veterans (2 of 6) Symptoms of PTSD incude feeings of: Hepessness Anxiety Fear 9

10 Fear Posttraumatic Stress Disorder and Returning Combat Veterans (3 of 6) Peope with PTSD: May avoid reminders of the trauma Suffer constant nervous system arousa Can reive the traumatic event through thoughts, nightmares, and Posttraumatic Stress Disorder and Returning Combat Veterans (4 of 6) Veterans have an increased risk of. Veterans may deveop a variety of physica conditions reated to combat injuries. Combat veterans have a higher incidence of traumatic brain injury (TBI). Posttraumatic Stress Disorder and Returning Combat Veterans (5 of 6) Caring for the combat veteran Requires a unique eve of understanding Be carefu how you phrase your questions. Use a cam, firm voice, but be in charge. Respect a veteran s persona space. Limit the of peope invoved. Ask about suicida intentions. Posttraumatic Stress Disorder and Returning Combat Veterans (6 of 6) Caring for the combat veteran Ensure that there is nothing the patient can access and use as a. Physica restraints may simpy escaate the probem. 10

11 . Physica restraints may simpy escaate the probem Medicoega Considerations Menta incapacity may take many forms. Once a patient has been determined to have an impaired menta capacity, you must decide if care is needed. Do not eave the patient. Obtain hep from aw enforcement as necessary. Consent When a patient is not mentay competent, the aw assumes that there is consent. The matter is not aways cear-cut with psychiatric emergencies If you are not sure about the situation, request aw enforcement assistance or guidance from medica contro Limited Lega Authority As an EMT-B, you have ega authority to require or force a patient to undergo emergency medica care when no ife-threatening emergency exists. Poice may put a patient in protective custody to aow you to provide care. Know your oca aws and protocos. In Texas, a peace officer may sign a protective custody form and have a patient committed for 24 to 72 hours. In psychiatric cases, a court of aw woud probaby consider your actions in providing ifesaving care to be appropriate. Err on the side of treatment and transport. Potentiay Vioent Patients Use a ist of risk factors to assess the eve of danger: Past history Scene Voca activity Physica activity 11

12 59 60 Physica activity Other Factors to Consider for Potentia Vioence Poor contro History of truancy, fighting, uncontroabe temper History of substance abuse Depression Functiona disorders Handing Psychiatric Emergencies Treat ony ife threatening emergencies. Do not remove restraints once appied. Stay cam. Attempt to patient. Do not turn your back on patient. Listen to patient. Maintain non-threatening posture. Maintain a means of. 12