Original Wu Fei Chat 686
The public is relatively familiar with the emergency department of general hospitals. For sudden physical diseases such as high fever, hemiplegia, coma and trauma, the emergency department of general hospitals is the first choice for treatment. So, what’s the difference between the emergency department in psychiatric department and the emergency department in general hospital? Under what circumstances should psychiatric emergency treatment be the first choice?
Next, I will take you into the psychiatric emergency room to show the real daily psychiatric emergency treatment.
Scene one
In front of the psychiatric emergency department, the 120 ambulance and the police car stopped in tandem, and a young man’s hands and feet on the 120 flat car were fixed by clothes and soft cloth belts. The boy shouted loudly, the content was messy, the speech speed was fast, and he wanted to break away from the constraints and was restless. Around 3-5 family members followed closely, and 120 staff and police escorted together. The scene was a little urgent, chaotic and crowded.
Scene 2
Young female college students came to the clinic accompanied by counselors. After entering the clinic, they asked the counselors to avoid it and whispered that they were under great academic pressure. It happened that they broke up with their boyfriends recently, which was very painful. They felt that life was hopeless and had suicidal thoughts. By cutting yourself, you will feel comfortable and relaxed when you see bleeding. Then you will take off the sunscreen cuff, and your arm will be exposed with shocking red wounds and rows of gray scars that have been cut with a small knife.
Scene 3
In the morning, a middle-aged woman came to the clinic, complaining of sudden palpitation, chest tightness and high blood pressure in recent months. I went to a general hospital for a cardiac examination, and no problems were found. The doctor suggested that I go to the psychiatric department and the patient is considering it. I woke up suddenly after falling asleep tonight, with a severe sense of suffocation, dying, flustered and sweating, and I was very scared. I felt that I couldn’t last tonight.
Scene 4
A mother and son were sent from 120 outside the hospital. The anxious young mother took the boy and called the doctor to see her before she entered the clinic. The patient has been seeing a doctor regularly in the children’s psychiatric clinic for the last two months. Yesterday, an antipsychotic drug was added to the clinic, and each patient took it once yesterday and today. At five o’clock this afternoon, my eyes turned upside down, my eyelids couldn’t be closed, I always looked up, my body tightened, my neck was stiff, my head tilted to one side, and I even walked sideways. It looked particularly uncomfortable. Mom anxiously asked the doctor what was going on.
Under what circumstances should I come to the psychiatric emergency department?
Emergency psychiatry is a branch of clinical psychiatry, and it is also a branch of emergency medicine. Medical staff mainly take emergency medical care measures for patients with mental disorders when they suddenly get sick or their condition suddenly worsens, endangering their own or others’ safety, and serious adverse drug reactions.
Let’s sum up the situation that needs to come to the psychiatric emergency department:
● Psychiatric emergency
Including excitement, injury and destruction, self-injury and suicide, serious hallucinations and delusions, numbness, refusal to eat and water, panic attacks and so on. Among them, excitement, self-injury and suicide are the most common reasons for psychiatric emergency treatment.
Specific performance includes:
Have impulsive tendencies, physical violence, verbal threats, or other risks that endanger the safety of others;
◆ Self-injury behaviors, such as cutting wrists and hitting walls; Or have a tendency to commit suicide, revealing suicidal thoughts to people around them, preparing suicide plans, or committing suicide such as overdose and jumping off a building (when serious physical problems have been caused, even life-threatening ones, you need to go to a general hospital first), such as scenario 2;
◆ Symptom of hallucination and delusion does not belong to psychiatric emergency, but if the content of hallucination and delusion may stimulate the above behaviors, it belongs to emergency category;
◆ Stunned, refusing food and water, or acute mental disorder, sudden nonsense, weird behavior, etc., such as scene 1;
◆ Acute anxiety attack, feeling of dying, flustered and breathless, panic, etc., as shown in Scene 3.
● Serious adverse reactions of psychotropic drugs.
Such as acute dystonia, malignant syndrome and 5-HT syndrome.
Acute dystonia is a kind of extrapyramidal syndrome, which is more than the early stage of taking antipsychotics, and often appears within 48 hours after the first medication. It can be manifested as upturned eyeball, torticollis, difficulty in opening mouth, choking with drinking water, and inverted horn arch. In severe cases, laryngeal muscle tension disorder occurs, which leads to upper respiratory tract obstruction, dyspnea and even life-threatening. This is the case in the fourth scene above.
Malignant syndrome (NMS) is a rare and life-threatening serious adverse drug reaction, which is mostly caused by taking a large number of antipsychotic drugs in combination. It is characterized by high fever, muscle tension, change of consciousness and autonomic nervous dysfunction. NMS may be complicated with rhabdomyolysis, arrhythmia and respiratory failure.
5-HT syndrome is also a potentially fatal syndrome, which usually occurs at the beginning of the use of 5-HT drugs or excessive use, and is rare at therapeutic doses. It is characterized by disturbance of consciousness, tremor, diarrhea, hyperreflexia, myoclonia and high fever.
Some of the above patients can be properly treated in psychiatric emergency. If there are serious comorbidities or life-threatening situations, they need to go to the general hospital for emergency treatment to stabilize their physical condition.
● Psychiatric drug overdose or poisoning
Such as lithium poisoning, antipsychotic poisoning and benzodiazepine poisoning. Note that people who have been poisoned by psychotropic drugs and have potentially life-threatening clinical conditions need to go to a general hospital for treatment first. Poisoning by other substances, such as pesticides, cleaning agents, pesticides, carbon monoxide, etc., should be treated in general hospitals first.
Lithium poisoning usually occurs in people who take lithium for a long time or by mistake. The therapeutic dose of lithium salt is similar to that of poisoning, so it is necessary to monitor the blood lithium concentration when using it. Mild lithium poisoning may cause dizziness, nausea, vomiting and diarrhea, and severe cases may cause limb tremor, nystagmus, ataxia, slurred speech, convulsion and coma.
The symptoms of antipsychotic drug poisoning are atypical, such as hypothermia or hyperthermia, blood pressure drop and even shock, coma, arrhythmia, abnormal electrocardiogram, seizures and so on.
People poisoned by benzodiazepines have a history of overdose or misuse of benzodiazepines, which are manifested as disturbance of consciousness, lethargy, coma, respiratory depression, bradycardia, decreased blood pressure, dizziness and ataxia.
● Mental disorders and acute withdrawal reactions caused by psychoactive substances such as alcohol, opioids, marijuana and central nervous system stimulants.
Alcohol is a psychoactive substance that is easy to obtain in China, so it is common for emergency patients to drink too much and have acute alcohol withdrawal.
Alcoholism is easy to identify. Patients who ingest a large amount of alcohol or alcoholic beverages will suffer from disturbance of consciousness, lethargy, coma, behavioral disorder, obvious ataxia, nystagmus, arrhythmia and shock within a short time.
Alcohol withdrawal refers to a series of symptoms caused by long-term heavy drinkers who suddenly stop drinking or reduce their drinking. There may be sweating, shaking hands, shortness of breath, tachycardia, elevated blood pressure, anxiety and insomnia, and in severe cases, hallucinations, seizures, tremors, delirium, etc., and even life-threatening.
It should be emphasized that when the vital signs of the above patients are basically stable, they can go to the psychiatric emergency department for treatment; If the vital signs are unstable, you should first go to the emergency department of a general hospital to stabilize the vital signs, and at the same time ask the psychiatric department for consultation, or refer to the psychiatric department for emergency treatment after the vital signs are stable.
● Individuals who have recently suffered mental and psychological trauma and suffered obvious social function damage.
Individuals are in an extremely painful and disoriented situation, which seriously affects social functions. For various reasons, when they are temporarily unable to go to the outpatient clinic, they can go to the emergency department for temporary treatment to help patients maintain a stable state before receiving outpatient treatment.
Under what circumstances don’t come to the psychiatric emergency?
● The patient did not come, and relatives and friends came to consult on behalf of the patient;
● Patients who regularly inject long-acting antipsychotics come for long-acting injections;
● Patients who can’t hang the outpatient number or find it difficult to register;
● Patients who need to issue various proof materials such as disease diagnosis;
● Minor patients (younger than 18 years old) must be accompanied by legal guardians;
● Patients with mental disorders who have caused physical injury due to self-injury or suicide, are in life-threatening situations, or are accompanied by consciousness disorder, serious physical illness, high fever, etc., need to go to a general hospital first.
Before reaching the psychiatric emergency department
How do family members cope with patients’ acute condition?
one
When there is an acute attack of mental illness and the patient is at risk of self-injury or injury, the family members should keep calm, find ways to protect the patient, prevent themselves and others from being injured, and send them to the hospital in time. If necessary, actively seek the help of other family and friends or emergency personnel, police, etc.
2
Calm patients’ emotions and avoid quarreling and direct eye contact. If there are sharp instruments beside the patient, try to take them away. If the patient has a sharp instrument in his hand to hurt others, stay away from him and ask the police for help as soon as possible.
three
When patients with mental illness have hallucinations and delusions, avoid arguing with patients about the authenticity of symptoms and seek professional guidance in time.
four
For those who have suicidal thoughts or attempts, or even have committed suicide by self-injury, their families should bring the patients to the hospital as soon as possible. For those who cannot be hospitalized immediately, their families should monitor them 24 hours a day, take care of the drugs and dangerous goods at home, or call the psychological rescue hotline.
five
For the early use of psychotropic drugs, during the period of increasing drug dosage or multi-drug combination, family members need to know the possible adverse drug reactions in advance, and slowly increase or decrease the dosage according to the doctor’s advice to avoid sudden increase or decrease of drugs. When the patient has the serious adverse reactions mentioned above, he should go to the emergency room in time.
six
If there is an overdose, the family members need to quickly identify and respond. When the patient is not sure about the drugs to take, collect the drugs that may be used around the patient, carry the information about drug use and empty medicine boxes, and seek medical advice in time.
seven
Patients with acute withdrawal reactions need to seek medical attention immediately, especially those with alcohol dependence. Wrong withdrawal may lead to serious withdrawal reactions and irreversible brain damage, and even life-threatening, requiring hospitalization or complete withdrawal under the guidance of a doctor.
In most cases, emergency patients have two places to go, hospitalization or outpatient treatment. For patients who can be referred to outpatient treatment, emergency doctors will help to deal with the current emergency, reduce excitement, reduce impulse risk, carry out suicide intervention, etc., to ensure that patients are in a relatively stable state before outpatient doctors receive treatment. For patients who need hospitalization, after receiving temporary emergency treatment, they are waiting for hospitalization according to the emergency hospitalization process.
In psychiatric emergency, ensuring safety is the most important thing, including patients’ physical safety and mental behavior safety, helping patients sort out and solve the most urgent and serious clinical conditions, and winning time and laying a foundation for receiving the next treatment.
Note: The pictures in this article are all from the Internet, so I apologize for the intrusion.
Author: Wu Fei
Peking University Sixth Hospital
Editor ||| He Yingying
Typesetting || White feather
Audit ||| He Xiaoxiao
Peking University sixth hospital gongbu
National mental health project office
Original title: "Guide to Psychiatric Emergency Treatment"
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