Behavioral Emergencies

Are mood, thinking or behavior of a patient highly unusual or disorganized whether the patient must first be decided upon,

Patients who experience severe changes in mood, thinking or behavior, or patients who have severe, potentially life-threatening adverse drug reactions must be evaluated and treated immediately. Often the first responders are not specialists in inpatients and outpatients; if possible, such cases should be evaluated by a psychiatrist. Are mood, thinking or behavior of a patient highly unusual or disorganized, it must first be decided whether the patient is a danger to themselves a danger to others is inherent risk, the inability for themselves to worry (which leads to self-neglect) or suicidal behavior include (suicidal behavior). Self-neglect, is restricted a particular problem in patients with psychotic disorders, dementia or substance abuse as their ability, even for food, clothing and adequate shelter to care. Among the patients who pose a threat to others, are actively violent (ie actively engage staff, throwing things and destroying things), the belligerent and hostile acts (ie they are potentially violent), and those who investigators said and do not appear threatening the staff, but specifically intend to cause harm to another person (eg. as spouse, neighbor, public figure). It is also important to identify caregivers who are unable to safely and properly care for their wards. Causes aggressive or violent patients are often psychotic and have diagnoses such as abuse of many substances, schizophrenia, delusional disorder or acute mania. Other causes are physical illnesses that cause acute delirium (s. Selected psychological symptoms because of physical disorders), chronic organic brain disease (eg. As dementia) and intoxication with alcohol or other substances, particularly methamphetamine, cocaine and sometimes phencyclidine ( PCP), and club drugs (eg. B. MDMA [3,4-methylenedioxymethamphetamine]). Any history of violence or aggression is a strong predictor of future episodes. General principles The management is typically composed simultaneously with the assessment, in particular the clarification of a possible physical illness (medical evaluation of a patient with psychological symptoms); it is a mistake to assume that the cause of the abnormal behavior is a mental disorder or intoxication, even in patients who have a known psychiatric diagnosis or alcohol smell. As patients are often not willing or able to provide a clear Ananmese, have other additional information (eg. As relatives, friends, social workers, medical records) are identified and consulted immediately. The physician must be aware that violence of patients to the treatment team and against other patients can be directed. Active violent patients must first fixed (immobilized) by mechanical aids drug (chemical immobilization) Both Such interventions are carried out to prevent harm to patients and others, and to permit the evaluation of the cause of the behavior (eg., By recording the vital signs and carrying out blood tests). Once the patient is fixed, close monitoring, sometimes with constant observation by a trained seat guard, is required. Medically stable patients can be accommodated in a safe, secluded area. Although the doctors of the legal issues in relation to a Zwangsehandlung (provisions for the use of mechanical restraints with aggressive, violent patients and behavioral emergencies: Legal considerations) must be aware they must not delay this potentially life-saving interventions. Potentially violent patients require measures to defuse the situation. Measures that can help to reduce agitation and aggression, are laying the patient in a calm, quiet environment (eg. As a secluded space, if available) removing objects that could be used to themselves or others to violate an expression of sympathetic interest for patients and their complaints responses in a sovereign, but supportive manner Ask what can be done to fix the cause of the anger Direct use-mention that the patients appear angry or upset, to ask them if they want to-detect hurt someone their feelings and can produce information; it does not make it more likely that they act out themselves. Counterproductive measures The validity of the fears and complaints of patients call into question threats eject (z. B. to call the police to teach them) speak in a condescending way trying to deceive the patient (eg. As hiding drugs in food, them promise they would not immobilized) personnel and public safety During talks with hostile, aggressive patients, the safety of personnel must be respected. In most hospitals, it is common to look at patients with Verhaltenensstörungen for weapons (manual, with metal detectors or both). Patients should be evaluated as possible in a secure area with surveillance cameras, metal detectors and in conversation rooms, which are available for employees. Patients who are indeed hostile, but not violent, typically do not attack the staff indiscriminately, but rather they attack people who annoy them or happen to them threatening. The room doors should be left open. Employees can also avoid to be threatening, placing themselves in the same height as the patient. Employees can avoid angering patients by not denominated in their hostility, angry remarks or disputes react. If the patients are still increasingly agitated and violence seems to threaten the staff should just leave the room and summon enough additional staff to provide a show of force, which sometimes deters patients. Typically should be at least 4 or 5 people there (some of which preferably young and male). However, the team should not bring items for fixing in the room when they are not relevant in any case; To see this, patients can agitate even more. Verbal threats must be taken seriously. If a patient is expressed to the effect of wanting to harm a person, be examined physician is required in most states of the United States to warn the potential victim and inform appropriate authority. The respective requirements vary from state to state. Usually require federal regulations that the suspected abuse or maltreatment of children, the elderly and spouses is reported. N. D. Red .: In Germany, the accommodation is in self – not federally, but regulated by state laws or danger to others, but which correspond in essential points. It must be given a disease and a serious danger to the patient himself or the general public. Placement in closed institutions may only when no other treatment option exists. Only the refusal of treatment is not a sufficient reason briefing. Each licensed physician is obliged to initiate the admission process in acute internal or external threat. For this, a short report is to be created and forwarded to the regulatory agency, which then brings about a court decision. The nature and extent of the disturbances must be clearly visible, and the extent of the obvious danger of being listed. The housing is placed by a judge; the person concerned may lodge an immediate appeal, even if he is incapacitated. Mechanical fixing The use of mechanical restraints is controversial and should be considered only when other methods have failed and a patient continues to pose a significant danger to themselves or others. Fixations may be needed so that the patient is kept quiet long enough to give him medication and / or to subject it to a full investigation. Since fixations be applied without the consent of the patient, certain legal and ethical issues to be considered (provisions for the use of mechanical restraints with aggressive, violent patients). Provisions for the use of mechanical restraints with aggressive, violent patients, the use of mechanical restraints should be considered as a last resort if other steps were not sufficient to control aggressive, potentially violent behavior. Be fixations required in such a situation, so they are legal in all states, as long as their use is properly requested and is documented in the patient record. Fixations have the advantage that they can be removed immediately, while drugs can completely change the symptoms or in a way that leads to the delay in the investigation. The guidelines of the Joint Commission for the use of force in the context of psychiatry state that fixations under the supervision of a licensed independent expert (LIP) must be applied. The LIP must assess the patient within the first hour after applying the fix. The arrangement continued fixation in adults may be given for up to 4 hours without interruption. The patient must be assessed by a LIP or a registered nurse during the 4-hour interval and prior to a further continuation of the fixation. After 8 hours, the LIP should re-evaluate before another Fixerung can be placed the patient in person. Children aged 9-17 years have every 2 h are judged children <9 years every hour. The accreditation standards for hospitals require that patients be fixed continuously supervised by a trained Sitzwache. Immediately after application of the fixation of the patient must be monitored for signs of injury; Circulation, range of motion, nutrition and hydration, vital signs, hygiene and excretion are also monitored. It also assesses how the patient feels physically and mentally, and whether he is willing that the fixation can be solved. These assessments should be made every 15 minutes. Seclusion and fixation should be used only under special circumstances and with continuous monitoring simultaneously. Fixations are used to prevent Clearly imminent harm to the patient or other avert Significant disruptions of medical treatment by the patient (eg., By pulling out needles or infusions) when the latter had given his consent to treatment destruction in the area, to prevent damage to personnel or other patients to prevent a patient who needs a compulsory treatment to prevent from leaving (if a closed space is not available) fixations should not be used as punishment for convenience of the staff (eg. as by walking around ) Caution is advised when apparently suicidal patients could use the fix as suicide instrument. Procedure fixations may only be created by employees who are properly trained in the proper techniques, respecting the patient's rights and safety. First, appropriate personnel gathered in the room, and patients should be informed that restraints must be created. Patients are encouraged to be cooperative and to avoid a confrontation. If the doctor has ruled, however, that restraints are necessary, which is not negotiable, and the patient is told that the fixations be created with or without their consent. Some even understand and are grateful that their conduct external borders are set. In preparation for the fixation is one person on an extremity and posted one at the head of the patient. Then each person should introduce its associated limb and places the patient in the supine position on the bed; a physically strong person can usually even with large, violent patients control a limb alone (assuming all extremities are taken simultaneously). However, another person is needed to apply the fix. In rare cases, it may be necessary to first pinch extremely pugnacious standing patients 2 mattresses. Leather straps are preferably used. It is ever applied to the ankles and wrists and secured to the bed frame, not the railing fixing. Fixations are not attached to the chest, neck or head, and (to prevent z. B. to spitting and cursing) Knebel are prohibited. (By trying z. B., knocking the carrier to bite or spit) patients remaining combative under Fixerung, require chemical Ruhigstellung.Komplikationen Agitated or violent people that are brought by the police to the hospital, almost always fixed (eg. as in handcuffs). Occasionally, young, healthy people in police shackles before or shortly after arrival at the hospital died. The cause is often unclear, but probably it consists of a combination of over-exertion followed by metabolic imbalance and hyperthermia, drug use, aspiration of gastric contents into the respiratory tract, embolism in people who were long tied up, and occasionally serious underlying medical conditions. Death is more likely in people who were fixed in a position in which one or both wrists were tied behind her back to the ankle; this type of fixation can lead to asphyxia and should therefore be omitted. Because of these complications violent patients, which are presented in police custody should be thoroughly assessed and released not as a mere socio behaviorales problem. Chemical immobilization Drug treatment should always aim at the control of specific symptoms. Medications patients can rest very quickly in the rule or be sedated with benzodiazepines antipsychotics (typically a conventional Antipsychotium, even an antipsychotic of 2nd generation can be used) These drugs are better titrated and act faster and more reliable if they i.v. be administered (see Fig. Drug therapy for agitated or violent patients), but the i.m. administration may be necessary if no iv access can be placed in patients who resist. Both classes of drugs are potent sedatives when agitated, violent patients. Benzodiazepines is likely given for stimulant overdose and alcohol and Benzodiazepinentzugssyndromen preference, and antipsychotics are preferably used in significant exacerbations known mental disorders. Sometimes a combination of both drugs is more effective; have high doses of a drug not the full desired effect, may instead continue to increase the dose of the first drug, keeping the use of a different class adverse reactions in check. agitated drug therapy at or violent patients Drug Dosage Comments Lorazepam 0.5-2 mg hourly i.m. (Deltoid) or iv if necessary, the iv administration is preferred because the absorption at i.m. injection can be erratic. Respiratory depression is possible. Haloperidol 1-10 mg p.o., i.m. (Deltoid) or iv hourly as needed (1 to 2.5 mg of slight anxiety and frail or elderly patients; 2.5-5 mg at moderate agitation; 5-10 mg for severe agitation) The drug is usually only necessary with obvious psychosis. The drug can worsen some intoxication with substances (eg. As phencyclidine) and lead to dystonia. To rapidly absorb a liquid concentrate can be used if the patient the drug p.o. can adopt. It occurs no respiratory depression. Ziprasidone 10-20 mg i.m. (Repetition of 10-mg dose every 2 h or 20 mg dose every 4 h possible; maximum 40 mg / day) ECG monitoring may be required. Concomitant use with carbamazepine and ketoconazole should be avoided. Adverse effects of benzodiazepines Parenteral benzodiazepines, especially in cans, as they are sometimes required when extremely violent patients, can cause respiratory depression. The management of breathing with intubation (restoring and securing the airway: endotracheal intubation) and ventilation may be required. The benzodiazepine flumazenil can be used, but caution is required because the original behavior problem may occur again if the sedation is significantly reversed. Benzodiazepines sometimes lead to further disinhibition of Verhaltens.Unerwünschte effects of antipsychotics antipsychotics, in particular, dopamine receptor antagonists, can both therapeutic as well as toxic dosage have acute extrapyramidal side effects (s. Treatment of acute adverse effects of anti-psychotics), incl. Summer t dystonia and akathisia (an unpleasant feeling of motor restlessness). These unwanted effects may be dose related and disappear with the discontinuation of the drug. Several antipsychotics, including thioridazine, haloperidol, olanzapine, risperidone and ziprasidone may cause long QT syndrome and thus ultimately increase the risk of fatal arrhythmias. NMS also is eligible (Neuroleptic Malignant Syndrome). Other adverse effects s. Conventional antipsychotics. Clinical calculator: QT interval correction (ECG) treatment of acute adverse effects of antipsychotics Symptoms Treatment Comments acute dystonic reactions (for example oculogyric crisis, torticollis.) Benztropine 2 mg i.v. or i.m. (Once after 20 can be repeated min) diphenhydramine 50 mg i.v. or i.m. every 20 minutes for 2 doses benztropine 2 mg p.o. may optionally together with an antipsychotic medication, prevent dystonia. Laryngeal Dystonia lorazepam 4 mg i.v. over 10 min, then slowly 1-2 mg i.v. It can be an intubation required. Akinesia, severe Parkinson's tremors, bradykinesia benztropine 1-2 mg po 2 times / day diphenhydramine 25-50 mg po 3 times / day For akinetic patients, it may be that the antipsychotic be discontinued and one has to use less potent. Akathisia (in other extrapyramidal symptoms) amantadine 100-150 mg po 2 times / day benztropine 1-2 mg po 2 times / day biperiden 1-4 mg p.o. 2 times / day Procyclidine 2.5-10 mg p.o. 2 times / day propranolol 10-30 mg po 3 times / day Trihexyphenidyl 2-7 mg po 2 times / day or 15 mg p.o. 3 times / day (or in retard form 2-7 mg of 2 times / day) The causative medication should be discontinued or a lower dose can be used. Akathisia, associated with extreme anxiety lorazepam 1 mg 3 times / day p.o. Clonazepam 0.5 mg of 2 times / day p.o. - Legal Considerations patients with severe changes in mood, thought or behavior are usually admitted to the hospital when her condition would without psychiatric intervention likely to deteriorate and are not available reasonable alternatives. Consent and compulsory treatment denying patients the hospitalization, the doctor must decide whether they are to be recorded against their will. An accommodation may be necessary to ensure the immediate safety of the patient and of other persons or to bring the medical examination to an end and initiate treatment. Criteria and procedures for inpatient involuntary treatment change depending on the case law. Usually a temporary fix requires the presence of a physician or psychologist and a weitereren doctor, a family member or close contact with this, to ensure that the patient is suffering from a mental disorder, is internally or externally endangering and refused voluntary treatment. Doctors should obtain the consent to medical treatment of minor children by parents or guardians. Own risk includes, but is not limited to suicidal ideations or behavior inability to meet basic needs, incl. Nutrition, shelter and needed medication in most jurisdictions is a healthcare moving by law obliged due to intervene with knowledge of a suicidal intent immediately to to prevent suicide, z. As by informing the police or other competent authority. Endangerment includes bringing others in danger expressing a murderous intention inability because of mental disorder for the needs or safety of dependents to care

Health Life Media Team

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