INTRODUCTION:
The psychiatric emergency bother. The patient confused, reluctant, hostile or violent, is never where it should be. The psychiatric emergency is not to succumb to the imitation of violence and panic, knowing that they are concerned for the whole entourage intense stress. Now this emotional mimicry is one of the main pitfalls of psychiatric emergency.
The doctor may be scared by the violence of a patient, which may distort clinical judgment and lead to inappropriate treatment decisions, even harmful. We need to know sometimes enter and withdraw.
The frequent question asked by the doctor involved in first line is: do I take care of the patient, the address psychiatric or call an ambulance? If the patient has never had to do with psychiatry, recourse to the general practitioner is often better accepted.
The psychiatric emergency work almost always has a social dimension, and the action or with the entourage is decisive.
Nothing can be decided regardless of the subject’s environment, especially, paradoxically, when it does not exist. The common economic and social problems of patients require that psychiatry is not alone in the field of emergency. The parallel development of a social home is often necessary. Thus the psychiatric emergency can not be excluded or isolated from its context, as may be temporarily a physical disorder.
The psychiatric emergency should be considered by the physician as a medical emergency.
The role of the first responder is often paramount.
A patient labeled “the seal of madness”, that is to say, labeled “mentally ill” is often not examined the somatic.
The risk is to ignore the organicity.
Indeed, any pathological agitation is not psychiatric (epileptic attack, stroke, subarachnoid hemorrhage, hypoglycemia, dehydration, etc.). Always look for an organic cause for agitation and not “as a psychiatric” all agitations.
But the reverse can happen: a hysterical pseudo-coma can be taken seriously and subject to attacks of invasive resuscitation protocol. It should also be wary of an initial medicalization of certain psychological situations.
There are also situations “mixed” where are entangled psychiatric and somatic disorders, such as some suicide attempts, pathological intoxication, drug addiction, or the stirring paintings, anxiety, confusion occurring in a organic disease (hypoglycemia, ectopic pregnancy, heart attack, etc.). The problems of addiction (alcohol, drugs, etc.) often exacerbate the situation.
The difference between psychiatric and emergency medical emergency is the fact that psychiatric diagnosis does not automatically lead to a precise protocol gestures, transfer and care. On the other hand, the diagnosis is not the major element of an initial interview in emergencies, the imperatives of the psychiatric emergency remainder primarily those of security (of the patient, his entourage and caregivers ).
As in any medical practice, physicians involved in the framework of emergency shall apply the administrative and ethical rules for practicing their profession, but the timeout, expensive psychiatrists, is rarely recommended in “crisis.”In the case of the isolated medicine in rural areas, for example, the general practitioner is often placed in situations that he must take to completion, without being able to appeal to niche players.
It is important not to confuse the different disorders that can affect a person and distinguish firstly, mental disorders associated with mental pathology proven and the other behavioral disorders are not the responsibility of psychiatry.The term psychiatric emergency includes both the psychiatric emergency work of a general hospital and emergency situations at home, at work or in a public place within psychiatry.
ADO-AGRESSIVITÉ- VIOLENCE:
The psychiatric emergency is often equated with agitation and aggression, but there are present where no agitation or aggression, especially in suicidal subjects.
Pathological agitation:
The pathological agitation is an increase in motor activity, inappropriate in form and in his strength, that is to say, messy and inconsistent.
It is characterized mainly by a loss of control of thoughts and actions. This is a translation of a psychic excitement in behavior. Agitation is not synonymous with violence. This can succeed agitation or appear suddenly. Sometimes, you have to respect the agitation which yield spontaneously.
The risk passes to self or heteroaggressive act are important in psychiatric agitations.
Aggressiveness:
Aggressiveness (from the Latin aggredi: attack) is an aggressive intent, no aggressive act.
It is a reaction to a frustration that has the effect of reducing frustration. Thus, the greater frustration and the greater the aggressiveness.
Violence is of course not specific to mental illness, but it can be a temporary symptom of a psychiatric condition. In most cases, several factors combine to determine the dangerousness (alcohol + personality + pathological jealousy, etc.). Some evidence to recognize the imminence of violence:
– Repeated violence history (verbal or physical);
– Chronic alcoholism or other addictions;
– Paranoid delusions and paranoid;
– Instability or motor restlessness (refusal to sit, stroll);
– Actions or words of threats or defense;
– Brutal and unexplained changes of activity;
– Unusual foul language;
– Port or use of weapon or object that could be used to attack;
– Prior record of violence.
Socio-demographic terms, the violence occurs more likely in men, aged between 15 and 24 years, of low socioeconomic level and with an absence or deficiency of social media.
EVALUATION-EXAMINATION METHODS:
There is no general method to conduct the examination of a person with behavioral disorders that puts into play especially the experience and personality of the observer (physician, nurse, policeman, etc.). Thus it is not to apply a “technical”, but to appeal to the good sense and skill. Every situation is approached differently. The review is still easier by some simple rules and valid in all cases.
It is best not to take notes during the observation and to focus on listening to the patient by trying to establish a dialogue. Avoid letting settle silence, often agonizing. So listen “pure”, so dear to some benevolent as it may be, is not desirable here. Listen to the patient does not say let the length about anything. You have to know direct dialogue and keep control. Also avoid the brutal interventions that may cause negative reaction in the patient, muteness or leak.
several steps we can distinguish in this review, steps are often conducted simultaneously.
Circumstances of the examination:
The general practitioner is often the front line in an emergency and can be disarmed by his lack of support, time or experience, a sense of failure, for his role as relay or by a feeling ” trapped “by the hostility of the patient. The role of the doctor in these situations is usually short-term, to ensure immediate safety and to confront a sometimes life-threatening.
Many emergencies treated by general practitioners without resorting to the psychiatrist, and psychological assistance that can bring general practitioner to a patient already knows that he is irreplaceable. When the doctor moves at home, on-site treatment is often the best solution, but it is not always possible. However, the separation of the medium can be in itself a therapeutic role and the reactions of the entourage (fatigue, fear, pain, aggression) must be taken into account. Sometimes the environment can be a big help by participating in the management. In the case of an isolated patient at home and unknown to the doctor, and regardless of the symptoms, the hospital use is preferred.
When the doctor receives a phone call, you have to immediately know the address and the patient’s phone number, required if the call is interrupted and the emergency should be sent home. If the patient is alone and the doctor feels it is in danger, the police or an ambulance should be alerted. At best, the doctor keeps the patient on the phone until help arrived, by calling them by a third party. Do not advise the patient to come only emergencies or firm.
In all cases :
– It is important to be familiar with local resources and circuits (EMS, police, gendarmerie, psychiatry guards, segmentation, etc.);
– An effort of patience and understanding is needed, what should any communication is interrupted. Now the dialogue, even small, can allow itself to initiate appropriate management;
– The doctor should always ask the following questions: who is calling for help? Who asked for help? That he should help relieve or cure? Because the patient may be voluntary, care applicant or otherwise forced by his entourage.
Observation of appearance:
Attention to the appearance of the patient is a diagnostic that should not be overlooked element. Are observed in particular:
– Dress: its degree of eccentricity, negligence, adjustment, etc. ;
– Face: lively, hilarious, anxious, confused, closed, sulky, sad, etc. ;
– Attitude: confident, friendly, suspicious, reticent, hostile, claimant, indifferent, etc. ;
– The movements and behavior: shiny, slow, hesitant, comic, aggressive, stupor, agitation, hyperactivity, tremors, tics, compulsions, stereotypies, mannerisms, etc.
Contact quality:
Contact is an unsung yet essential element of the review of analyzing his own reaction to the subject. It is a means of investigation facilitated by the experience but accessible to any observer who agrees to spend a few seconds to his “self-observation”, that is to say that it feels at first contact with the patient. In current practice, the diagnosis is of course based on more objective, but in an emergency, this awareness that “clears” the subject is not superfluous.
These items are more objective evaluation of mood, alertness, lucidity, discourse analysis.
Collection of anamnestic data:
This can be done with the subject if possible, but it occurs most often with the entourage. Are sought in particular:
– Vital elements;
– Circumstances of the onset of the crisis: the beginning (sudden or gradual), recent or ancient life events precipitating events, the social, the order of appearance of symptoms;
– Notion of prior access;
– Ongoing treatment, the use of psychotropic or toxic;
– Somatic and personal and family psychiatric history.
Physical examination:
Faced with an acute psychiatric presentation, aetiology or organic participation may be overlooked. The mistake here can be life-threatening. Thus, caution incentive to move first towards an organic etiology, especially in front of a painting “Psychiatric look” sudden onset.
This physical examination is essential for diagnosis but can be done in a peaceful climate. In any case, we must achieve a summary assessment of the patient’s general condition, and this examination is particularly oriented towards research of signs of alcohol intoxication (acute or chronic) or addiction.
Neurological examination is also essential.
When in doubt, clinical examination is supplemented by additional tests: blood sugar, CBC, serum electrolytes, urea, creatinine, chest x-ray, ECG, research toxic (blood and urine) or CT scan, EEG, fundus , lumbar puncture, etc.
Features moving towards an organic etiology of mental disorders:
The features moving towards an organic etiology of mental disorders are:
– Sudden onset;
– No triggering event;
– No known psychiatric history;
– Old person ;
– About not expressing himself or evil;
– Somatic history or current condition;
– Substance abuse;
– Neurological symptoms;
– Delirium.
_ Main organic causes of behavioral disorders
Neurological causes:
Neurological causes concern:
– Encephalitis;
– Subarachnoid hemorrhage;
– Epilepsy;
– Cerebral arteriosclerosis lesions;
– Temporal lobe disease;
– Brain tumors;
– Dementias.
Extra-neurological causes:
The extra-neurological causes concern:
– ++++ Hypoglycemia;
– pulmonary embolism ;
– Initial phase of myocardial infarction;
– Cardiac arrhythmias;
– Bacterial endocarditis;
– internal bleeding ;
– High blood pressure;
– Hyperthyroidism;
– Hyper- or hypocalcemia; pheochromocytoma.
– Attention to mixed or associated pathologies: organic and psychiatric.
CLINICAL TABLES:
Access maniac:
The manic requires particular attention to behavioral outbursts.
This is a stirring table “pure” and “sterile”. It is characterized by psychomotor hyperactivity (back-and-forth gestures, dance, etc.), behavior that amused by his playfulness. Thus, the maniac communicates with an unusual entourage but transient gaiety. Dress is often extravagant. The mood is euphoric, expansive, sometimes ironic or caustic and versatile (transition from laughter to tears, anger, lamentation, etc.). The subject is hilarious (and sometimes a dark humor), hypervigilant (very attentive, nothing escapes him). The speech is fast, scrappy, imaginative, marked by a wordy, peppered with jokes, puns, wordplay, pass the “one subject to another,” showing a flight of ideas. The subject sometimes expresses megalomaniacal delusions or grandeur. To a lesser degree, it is called hypomania.
Before a manic, are sought psychiatric personal and family history, looking for a bipolar disorder. This type of table usually requires a psychiatric hospital environment. But these patients can become threatening and violent in opposing any proposal care and, a fortiori, to hospitalization.
Melancholy access:
The melancholy access must prevent suicide risk. (See chapter, From sadness to depression)
Confusional access:
The confusional access points of a medical emergency.
Confusional state requires a thorough clinical examination to find an organic cause.
The main signs are:
– A neglected aspect, a bewildered air, absent, puzzled;
– A contact that inspires pity and that makes you want to attend the topic;
– Cognitive disorders: memory disorders, attachment with amnesia forgetting to measure (test 3 words), disorientation temporospatial, dissolution of consciousness;
– Confuso-dreamlike access with visual hallucinations and / or hearing that may cause leakage gestures or potentially dangerous defense;
– Inertia or stupor or disorderly agitation;
– Awkward movements, dysarthria;
– Paroxysmal anxiety;
– Vagrancy;
– Altered physical examination.
Minor confusion or intermittent forms are more difficult to diagnose.
What to do before a confusion:
What to do before a confusion must allow an emergency transfer to the general hospital in good conditions:
– Permanent presence reassuring;
– Close monitoring: risk of sudden change in behavior;
– Report to sick and do not ask too specific issues;
– Thorough examination of the environment;
– Not to immediately psychotropic risk of still impair consciousness;
– Prevent dehydration.
Main causes confusion:
Alcohol:
The alcoholic etiology is most common. She understands :
– Acute intoxication: regressive transient confusional state within hours followed by amnesia;
– Withdrawal syndrome: subacute delirium often nocturnal beginning, terror, visual hallucinations, zoopsies, dreamlike lived, mobile, kaleidoscopic, anxiety, brief moments of lucidity, sweating, trembling.
Somatic or iatrogenic:
The somatic or iatrogenic causes are common among the elderly. They are found in the following conditions:
– Subarachnoid hemorrhage;
– Hypoglycemia;
– Endocrine and metabolic diseases;
– Chronic poisoning (barbiturates, lithium, atropine);
– Infectious disease;
– Addictive withdrawal;
– Postcritical epilepsy;
– Encephalitis.
Psychiatric disorders:
Psychiatric disorders include:
– Hysteria fugues, amnesia, transient dissociative states;
– Schizophrenia;
– Puerperal psychosis;
– Psychiatric disorders in the elderly;
– Acute delusional episode;
– Melancholy or mania.
Acute anxiety attack or generalized anxiety attack:
very common cause of unrest, most often, the patient himself requests an emergency consultation. This is usually a reaction to a traumatic crisis event in a neurotic subject. The more the subject is neurotic (suggestible, fragile), less intense may be the event that triggers the crisis. After a catastrophic event that suddenly confronts the subject with death or the idea of it, any individual can make an anxiety attack. Often referred to these attacks “hysterical” derogatory term in the common sense and not always adequate in this situation.
These crises are characterized by the following conditions:
– Hyperexpressivité Topic (crying, screaming, moaning, etc.) with an exaggeration and theatricality in the presentation and the speech that impair contact with him and inspires mostly irritation. Thus, the intensity of the manifestations of anxiety can “infect” the examiner. The subject is anxious, confused-emotional but not, except in the rare case of confounding reaction after severe psychological trauma;
– Usually elusive and repetitive speech and characterized by the use of superlatives and a lack of objectivity;
– Imminent sense of danger and indescribable that the patient often struggle to verbalize (fear of going crazy, not to be controlled, etc.); a sense of frustration, fragmentation of thought; physical sensations of choking, unconscious, near death, sometimes associated with various somatic complaints. In these cases, it is common that the patient requests additional examinations.
When acute anxiety attacks are repeated, it is called panic disorder, which joins the fear of having another attack (anticipatory anxiety).
To behave :
Once organic causes apart, you must:
– Explore with the patient situations that may have been the cause of the crisis: conflicts, overwork and exhaustion, physical trauma, or severe chronic somatic disorders causing fear of death or abandonment, etc.
– Search for recent withdrawal “involuntary” benzodiazepine short half-life;
– Dramatize a reassuring maintenance;
– Deal with sedative if needed;
– In case of failure of these simple measures, the use of psychiatric consultation and even hospitalization may be necessary.
Main organic etiologies of acute anxiety attack:
The main organic etiologies of acute anxiety attack include:
– Hypoglycemia;
– Alcohol, toxic and iatrogenic (or abuse cessation);
– Viral encephalitis;
– Malignant hypertension;
– Intracranial hypertension;
– Meniere’s syndrome;
– Internal bleeding.
Characterial agitation:
The temperamental agitation occurs in individuals with a personality disorder of borderline type or hysterical psychopath.
The behavior is readily theatrical discourse marked by untimely and inappropriate accusations involving the doctor’s responsibility. In this context, it is necessary to adopt a neutral attitude and not respond to provocations.
Psychopathy is characterized by impulsivity, intolerance to frustration, threats to the environment, a perpetual attitude of resentment, criminal acts. It usually involves young males, often with a criminal record, professional and emotional instability. frequently found in their history of early and repeated emotional or physical deficiencies.
Acute delirious flashes or acute psychotic episodes:
In these cases, there is a break of contact with reality and the subject is not aware of the pathological nature of its conduct.
The patient’s appearance rather frozen before the onset brutally stirring crisis seemingly unmotivated and rationally inexplicable.
The look is absent, the impairment in communication is obvious and that is why these patients are afraid for no objective reason related to a real danger. The reason for the fear is to intuitively perceive the chaos of thought and the discordance of discourse and behavior. The topic under indifferent, but vigilance is not altered. His speech is difficult to understand, his words are often hermetic, bizarre or totally inconsistent.
It can be either a single acute episode of delirium or acute decompensation of a phase of a chronic psychosis or “fertile moment”, hence the importance of the history and background.
Puffs delirious or acute psychotic episodes:
Onset is rapid, a few days maximum, sometimes within hours. It may be preceded by a stressor (bereavement, psychological trauma, etc.), or occur without triggering net element. The disorder does not last more than a month.The episode occurs most often in adolescents or young adults.
The disorders vary from one moment to another and are: emotional instability: passage of depression with anxiety to exhilaration and excitement phases;
– Conflicting attitudes doctor: feelings of sympathy, mistrust or hostility;
– Absorption of the subject in an imaginary life, speaking in a disorganized speech;
– Delirium polymorphic in its themes and its mechanisms, not systematized. Membership in delirium is variable: the subject can pass from a conviction
intense with a questioning perplexity;
– Denial of the pathological disorders;
– Frequent mental or sensory hallucinations (listening attitudes during auditory hallucinations);
– Duplication of feeling;
– Highly variable behavioral disorders;
– High risk of suicide, particularly in young patients.
In young subjects, the origin of this toxic delirium and the absence of psychiatric history are common.
Acute phases of decompensation and chronic psychoses (schizophrenia):
The beginning is here more progressive, often following a stress trigger (change of everyday life of a schizophrenic, for example).
Clinical features include the following disorders:
– Net dissociation: disorders of the course of thought, unmotivated smiles, dams, etc.
– Breaking contact with reality;
– Inconsistency of thought and language;
– Emotional indifference;
– Blurred speech, abstract, meaningless and without emotional involvement;
– Delusions of themes and various mechanisms;
– History and patient history revealed the diagnosis of known chronic psychosis.
Crossing the untimely act hetero aggressive are more common in chronic psychotic who “decompensate” (schizophrenic) than in acute delirious episodes.
Sometimes inaugural, they reflect the ambivalence of these patients: hate or intense and brief attachment. This is the brutal character, unexpected and unusual of these passages to the act that make them dangerous.
All discordant patient can present sudden and aberrant behavior changes.
What to do before an acute psychotic episode:
What to do before an acute psychotic episode should focus on:
– Eliminate mental confusion: the bizarre behavior, lack of attention, the intermittent silence, latency responses, lack of mental synthesis may make it difficult to distinguish between delirium and confusion.
However, it does not exist mostly in psychotic episodes of disorientation temporospatial;
– Ask simple questions in reassuring terms;
– Not to adopt a threatening attitude at the refusal of almost systematic care of these patients;
– Do not expect the emergence of behavioral problems for action: a psychiatric hospital environment is essential.
_ Main organic etiologies of acute delirious episodes
Toxic causes:
Toxic causes are:
– Alcohol, cannabis, LSD, PCP (phencyclidine or “crystal” or “angel dust”), amphetamines;
– Drug overdoses (deliberate or accidental): insulin, tricyclic, corticosteroids, isoniazid, Artane® (antiparkinsonian), cimetidine, thyroid hormones.
Neurological causes:
Neurological causes are:
– Encephalitis;
– Temporal lobe epilepsy;
– Subarachnoid hemorrhage;
– Meningitis;
– Severe hyperthermia;
– Intracranial hypertension;
– Acute intermittent porphyria;
– Toxic professionals.
Paranoia (personality and / or delirium):
Paranoia is a significant danger. The subject threatening, unlike the restless, is able to explain. A dialogue can generally be established, although it is sometimes deliberately refused. The speech is often made claims and / or threats, and the patient is in total denial of its status ill.
The presentation of the paranoid patient is usually quite conventional, but in anger, it can exhibit aggressive behavior disorders. Moreover, certain moments of exaltation can be the cause of various offenses: public scandals, death threats, damage to property, etc.
We distinguish paranoid personality marked by psychorigidité, mistrust, suspicion, reticence, self-overestimation, and paranoid delusions, envy, persecution, injustice or erotomaniacal. When the subject delirium, agitation occurs depending on the intensity and nature of delusional beliefs.
The paranoia often leads us into a discussion without end, quite inappropriate in this context of urgency, which is called “paralogical reasoning.” His mood can be exalted or marked by aggressiveness. Vigilance is not altered.
Paranoia, especially in his delirious form, can be dangerous. This is indeed one of the most criminogenic psychiatric disorders, threatening relatives or “designated persecutors” of the patient.
This danger is further enhanced when the alcoholic is paranoid.
Reticence and silence:
The reticence and silence required patience.
Mutism:
Mutism is a disorder of the psychic origin of communication, resulting in a lack of response or even contact, while messages of the examiner tries to establish a dialogue are perceived by the patient. It combines the silence reluctance or mistrust, that are attenuated forms. These attitudes require a prolonged interrogation. Faced with this type of patient, it must first rule out confusion, and search poisoning, then attempt to establish communication with calm and patience. We can give the conversation an almost confidential, approaching the patient physically. Do not hesitate to repeat words or phrases. Sometimes the patient starts talking when we ended the interview.
In all cases, take his time, respect and stand the silence, extend maintenance to try to “break the ice” and sometimes appeal to another party.
When the patient breaks his silence with another party, we speak of silence “selective”.
Attention silence is sometimes caused by a clumsy attitude, intrusive or pressed by the examiner.
The silence at various etiologies: access melancholy, hysteria or other personality disorder, delirium, especially of persecution.
Negativism:
Negativity is a lack of response to orders and instructions from outside. The patient opposes a stubborn resistance to any attempt to mobilize. Negativism is sometimes accompanied by urinary retention and / or faeces.
Catatonia:
Catatonia, the most severe form, is characterized by the alternation of clinical pictures which follow: negativistic phases, passive and expressive.
Phase negativistic:
The most frequently observed, it is of varying intensity.
The patient is frozen, petrified, indifferent, mute. Mobilizing members is impossible, sphincter retention and refusal to eat are common.
Passive phase:
The passive phase is characterized by diminished resistance to mobilization or “waxy flexibility”. It causes persistent attitudes caused no apparent muscle fatigue, sometimes mimicking the speech and gestures of the interlocutor.Suggestibility is intense: execution and immediate answers to questions.
Expressive phase:
The expressive phase can occur between the two previous phases. The signs are stereotyped attitudes, automated, artificial gestures, psychomotor discharges up to furious bouts with shouts and uncontrolled violence.
Catatonic paintings evoke primarily schizophrenia, but can be observed in melancholy access (melancholy stupor).
In all cases, hospitalization is required.
Main organic etiologies of inhibition states:
The main organic etiologies of inhibition statements concern:
– Carbon monoxide poisoning;
– Infectious diseases (brucellosis, typhoid);
– Hypoglycemia;
– Hypercalcemia;
– Hyperparathyroidism;
– hypothyroidism ;
– Neuroleptic malignant syndrome;
– Intracranial hypertension;
– Brain tumors;
– B1 vitamin deficiency (M ise ase Wernicke).
Alcohol:
Alcohol is the most common cause of psychiatric emergencies. It is in France at the origin of most of the problems encountered in the emergency behavior, and the potential danger of a patient is always increased by intoxication.There are three main types of table: acute intoxication, withdrawal syndromes and complications of chronic alcoholism.
Intoxication or acute alcohol intoxication:
Acute alcohol intoxication demonstrates the action of a strong dose of alcohol on the central nervous system. The effect is first stimulant and depressant and hypnotic. The potential danger of an alcoholic patient is that inhibitions alcohol, clears prohibited and multiplies the impulses. Clinical manifestations of intoxication depend on the absorbed dose of alcohol, speed of absorption and subject characteristics (gender, age, previous habits of drinks, associated drugs, etc.). The pathological manifestations can occur with less than 1 g / L of alcohol in the blood.
Remember also the mutual potentiation of alcohol and psychotropic drugs.
The three phases of drunkenness:
The three phases of drunkenness are:
– Psychic excitement: talkativeness, euphoria or anxiety, irritability;
– Drunkenness: cerebellar symptomatology characterized by motor incoordination and gestures, tremors, slurred speech, gestures and words incongruous;
– Sleep: including coma.
Pathological intoxication:
It is drunkenness associated with other psychiatric disorders: excitomotor intoxication is the most dangerous form of intoxication resulting in great excitement with aggressive impulses without limit and a high risk of suicide, d ‘offenses or homicide.
Also visible manic intoxication (euphoria, expansiveness, logorrhée), depressed intoxication (of inhibitions and suicidal risk), the delirious rapture (the most frequent themes of delirium are persecution, megalomania, jealousy or self-incrimination) and confuso-dreamy intoxication (illusions or visual hallucinations, impaired consciousness).
What to do before an intoxication:
Drunkenness requires a complete physical examination.
Oenolique a breath t does not suffice for the diagnosis.
If the intoxication diagnosis is often obvious, it is important to look for organic manifestations associated (hypoglycemia, head trauma, etc.).
The following rules are observed:
– Permanent medical supervision (risk of coma);
– Measurement of blood alcohol and blood sugar balance
Organic depending on the context;
– In case of simple drunkenness, the medical community at rest enough;
– In case of pathological intoxication with agitation, sedation is required (Valium or Loxapac®) under supervision.
Withdrawal syndromes:
These are disorders related with alcohol dependence, occurring during a stop or a net decrease of a former alcoholic intoxication. The troubles reflect a hyperactivity of the central nervous system previously inhibited by alcohol.
Prédelirium tremens:
The most common moderate forms are:
– End and distal tremor accentuated movements, also involving the tongue and lips;
– Hypertension oppositional;
– Anxiety, irritability sometimes aggressiveness;
– Sweating, diarrhea, tachycardia;
– Insomnia;
– Depressive symptoms.
This state disappears under treatment in 3 to 5 days. The treatment is well codified, according to a “withdrawal score,” involving hospitalization, rehydration, vitamin B1, B6, PP, Valium (all times as the score remains high).
Delirium tremens:
Delirium tremens can be fatal and reports of the medical emergency.
It may be preceded by an epileptic attack, pre-DT or subacute delirium.
Clinical picture:
Its features are:
– High intensity tremor, affecting the entire body, causing gait disturbance and speech;
– Marked oppositional hypertension;
– Delirium confuso-dream: disorderly agitation, aggression, fear or threats, visual and auditory hallucinations, interpretative delirium, confusion;
– Sweating, vomiting, diarrhea, causing dehydration;
– Fever;
– Tachycardia;
– Hypernatremia;
– Haemoconcentration;
– Increased serum creatinine;
– Biological stigmata of chronic alcoholism: elevated transaminases, gamma-GT, mean corpuscular volume.
Treatment:
Treatment includes:
– Hospitalization in lit room;
– Intravenous rehydration;
– Valium;
– Ionic rebalancing;
– Vitamin therapy B1, B6, PP;
– Neuroleptics in case of delirium.
In these conventional weaning tables may associate seizures and panic attacks vesperal among abstinent alcoholics.
Complications of chronic alcoholism:
The complications of alcoholism include:
– Symptoms of moral and intellectual deterioration;
– Indifference to moral and emotional degradation;
– Mood disorders and character;
– Incoherent, dysarthria, verbal perseveration;
– Confusion, confusion;
– Seizures;
– Acute alcohol syndrome encephalopathy or Wernicke: complication of alcoholism secondary to vitamin deficiency involving a disorder of eye movements, cerebellar ataxia and confusion;
– Alcoholic dementia or Korsakoff Syndrome: amnesia and confabulation.
Disorders related to other toxic behavior:
All toxic can provide behavioral and represent medical and psychiatric emergencies. The variety of products used explains the diversity of clinical pictures. Moreover, the toxic associations are frequent, increasing the risk.
We distinguish :
– Hallucinogens, cannabis, LSD, PCP;
– Euphoric: opiates, cocaine;
– Stimulants: amphetamines and derivatives;
– Tranquilizers benzodiazepines, barbiturates;
– Organic solvents: ether, trichlorethylene.
These products can give for intoxication or withdrawal:
– Acute delirious episodes (hallucinations, depersonalization, persecution syndrome, etc.);
– Confounding arrays;
– States of agitation;
– Depressive syndromes.
SPECIAL CONDITIONS:
Psychiatric emergencies in the elderly:
Psychiatric emergencies in the elderly are characterized by the frequency of associated organic disorders and iatrogenic disorders.
The risk of dehydration and malnutrition require hospitalization.
Agitation senile and insane:
The clinical picture of senile dementia and agitation concerning:
– Confusional state of variable intensity;
– Anterograde amnesia;
– Decrease in verbal activity;
– Stereotypical psychomotor activity;
– Negativistic or aggressive behavior.
Anxious raptus:
The clinical picture of anxious raptus concerns intense agitation. The triggering cause is sometimes trivial or minimal.The reassuring maintenance is sometimes enough.
Depression:
The clinical picture of depression concerns:
– Immobility, bed rest;
– Silence, sulking;
– Food refusal;
– Postictal amnesia.
Psychiatric emergencies and puerperium:
They are more common in first-time mothers and are partly explained by the hormonal factor.
During pregnancy:
Psychiatric disorders are rare because pregnancy exert a protective action vis-à-vis severe psychiatric disorders.
However, anxiety disorders are common, especially during the 1st quarter. The role of the general practitioner is essential when it knows the woman and that there is a relationship of trust.
The use of chemotherapy should be minimized. Melancholic depressions are rare and usually occur after the 5th month, sometimes with confusion or delirium. Hospitalization is required.
During postpartum:
There are 3 tables of increasing severity:
– Baby blues or postpartum blues is not an emergency: the symptoms are mild and transient;
– Postpartum depression;
– Postpartum psychosis: vital risk to the newborn and maximum risk during the first month. They require immediate hospitalization in a specialized environment.
PIPES TO KEEP:
Attitude:
The attitude of one who is involved, whatever its function, is supposed to have therapeutic value at first contact: sometimes the simple firm persuasion, not aggressive, enough to calm the subject, but sometimes the use of more methods ‘violent’ is required. In any psychiatric emergency, contact quality of physician empathy and expertise are paramount.
The agitated agitated entourage: it is a well-known contamination phenomenon is explained by a momentary failure of verbal communication. In all cases, we try to avoid showing his own fear or anxiety.
The main goal is to achieve a minimum restore communication with these patients while preserving its own security (Box 1).
Box 1. Safety rules to be observed in psychiatric emergency
Protect yourself: stay alert to the risk of imminent violence and not try only to physically restrain an agitated patient
Ensure the environmental safety conditions: get in a quiet space, but open
Do not impose the patient to be still, sitting or lying less
Perform maintenance standing, without turning their backs on
Keep a distance of at least the length of an arm
Remove glasses, pens, sharp objects, etc., in order to prevent a self act or hetero aggressive
Discard the entourage
If the subject has a gun, do not seek to recover any cost, because it may be the only defense against his anxiety about
Appear without subterfuge, stating his medical office and appeasement intention
Questions short, concise and direct: how can I help you, tell me what’s happening or what happened
Avoid stereotyping gender issues “police investigation”
Start by addressing non-contentious issues and learn to change the subject if the theme provokes violent reactions
Never speak louder than the patient
Do not share its incomprehension
Know sometimes get help from a member of the entourage reassuring
Offer the patient food or drink
Establish close monitoring
Tell entourage in case of danger
Do not hesitate to call the police (police and gendarmerie)
Never respond immediately to the agitation by force
Avoid leaving it alone or single patient with an isolated speaker
Medications:
The use of medication is often needed at best orally when the patient is willing, if not by injection.
There is indeed no question of letting develop anxiety to fury, but you have to understand, if possible to the patient and the environment, the treatment is only the beginning of taking load, it will allow to resume the dialogue, and that it is not an end in itself. Symptomatic treatment is administered sedative focus, which then allows to conduct a psychiatric examination in the best conditions.
The main indications of drug treatment in emergency include violent or aggressive behavior, massive anxiety or psychotic disorders original behavior.
Whatever the reason (apart from organic causes whose treatment is specific), any intense agitation requires an injectable treatment, fast and efficient. currently most often used neuroleptic Loxapac® (max. 50 mg), drug fast action and no interaction with any decision-toxic. Antipsychotic drugs can be administered at 30-60 minute intervals.
After taking antipsychotic, there is always a risk of extrapyramidal syndrome within 24 hours.
In minor forms of agitation or anxiety, anxiolytic treatment often enough t or by benzodiazepines: Valium (diazepam), Tranxène® (clorazepate); either Atarax®, causing neither addictive nor habit, and recommended in pregnant women.
The dosages are adapted to the age, history and clinical status. Beware of respiratory problems and elderly.
Before drug administration:
– Inform the patient;
– Control constants;
– Use mediation of a nurse or relative to accept treatment;
– Show that the patient has the means and determination to oppose the realization of his threats;
– Avoid sedative drug combinations and the low doses and unnecessary.
Physical Restraint:
It is an emergency measure to which we must sometimes resort. If it is unjustified and pathogenic in certain situations, it may be therapeutic in others. It is a decision that is not easy to take and which we must measure the psychological, and especially appreciate the immediate benefits.
This contention is not to pure repression, but security.
It must always be accompanied by a sedative medication. It allows a return to relative calm, restoration of boundaries by ending with behavioral disorders, and to control agitation and aggression become intolerable and source of suffering for the patient. It is used for patients dangerous to themselves or to others otherwise uncontrollable. It is always temporary.
Most often, patients and “content” subside quickly.
We must let you perform this procedure to those in habit.
Those with humanism and unconsciousness oppose systematically sometimes can cause dramatic consequences.
When the doctor decides to contention, it must comply with certain rules, the most important are ethical:
– The physician must act knowingly and not to submit to the exclusive judgment or pressure from some members of the entourage;
– It must ensure that the persons with the act with humanity and respect for the patient;
– It must try to explain to the patient the reasons and the merits of such a measure.
The practice must observe the following rules:
– In case of imminent danger and lack of staff, it is better to let the patient and immediately call the police;
– Do not try to “bargain”: once the decision is made, it must be implemented quickly;
– At best, five people are needed to establish the contention: one to supervise and one for each member. In all cases, never less than two;
– An attached patient must be under constant supervision and never be left alone;
– An intravenous first should always be accessible;
– The patient’s head should be slightly raised to decrease the sense of vulnerability and reduce the risk of inhalation;
– Restraints should be checked regularly for safety and comfort (circulation in the limbs);
– Always part of the patient record the pattern and duration of restraint, treatment, patient response;
– Unwarranted or awkward it is, the main risk of contention is that of his untimely emergence. Before releasing maneuver, prudence dictates to analyze the situation and appreciate the high risk of explosion immobility imposed on the patient.
Hospitalization:
We must ask three questions:
– Is it necessary or not to hospitalize the patient?
– If so, what type of structure: health service or psychiatry? In case of suspicion of organicity, the direction to take is that of the general hospital;
– If a psychiatric hospitalization is necessary, in which mode: free (HL), at the request of one third (HDT) or office (HO)?
The hospitalization decision is made based on the degree of agitation, duration, opportunities to reduce on site. It also depends on the pathology in question and the foreseeable future risks: acting out self or hetero aggressive.
Regarding the agreement of the patient to the hospital, it mainly depends on its capacity to consent to care. Psychiatric hospitalization procedures are provided by the Law of 27 June 1990. It takes three conditions for applying that law and hospitalize a patient against his will:
– Existence of a hazard;
– Existence of a psychiatric disorder;
– Direct link between the two.
The legal framework for these hospitalizations without consent takes into account not only the protection of society, but also, and especially, that of the patient, that hardly makes a large number of civil libertarians.
Public psychiatry in France is sectored.
The area is defi ned by a territory and a population.
This population should theoretically be able to count on a specialized team to ensure: all psychiatric extra- and intra-hospital;
– Continuity of supported;
– Free health care.
An HDT requires an application for third and two medical certificates. HO is justified when the psychiatric disorder jeopardize public order or security of persons and then requires a prefectural (municipal or emergency) made in pursuance of a medical certificate. The doctor should know the local resources in terms of hospitalization (area mental hospital, mental health center, etc.).
If the doctor decides to hospitalization, he should prepare for it (whenever possible) and the patient’s entourage. The psychiatric hospitalization is often unpopular. The psychiatric stay even mark an “indelible stain” the patient and his entourage.
On the other hand, psychiatric hospitals are often far which complicates the role of the family.
Sometimes the patient himself asks his hospitalization.
He tries to justify it by symptoms, a claim, a remedy or right. In these cases, hospitalization is often more social than health. Hospitalize a patient in environmental disruption is a decision whose consequences must be considered: it is expensive and especially when it is unnecessary, it can maintain or intensify psychological disability, or even create a disability.
Transport:
The paramedic in charge of transport a patient involved in the therapeutic action. Its knowledge determines the quality of care. It must be neither too cold nor too warm. Transportation must be best assured in awake patients, because it is dangerous to travel about a comatose single ambulance. Transportation must be carried by two people. Sometimes it is useful to accompany the patient by a member of his entourage.
CONCLUSION:
The number of psychiatric emergencies is increasing due to several factors: increased violence and illicit substances, reduced tolerance to economic and social difficulties and less resistance to “accidents of life” (loneliness, housing, unemployment, etc.). This requires that psychiatry is not alone in the field of emergency.
The role of the GP is often essential in the early days of the emergency, especially since he often shared with patients and their family realities that psychiatrists ignore. Unfortunately, the urgency attached by the doctor often comes in loneliness, lack of time, lack of understanding, feeling of being disarmed, etc.
Sometimes there is a dramatization of emergencies, so that the occurrence of some of them could be avoided if starts was up a stronger collaboration between general practitioners and psychiatrists.
The imperatives of urgency, often in psychiatry those of security, should take precedence over administrative rules.
Unfortunately, frequent stiffness of psychiatry segmentation system is often opposed to this reality.
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