A psychiatric emergency refers to any disturbance in a patient's thinking, emotions, or behavior that requires immediate intervention. This disruption usually puts patients in critical condition, which can put themselves, their family, and people around them in danger. These emergencies include hurting others or themselves, aggression, restlessness, acute behavioral symptoms caused by drug poisoning, depression, and severe anxiety (13).
It is essential to distinguish between the physical and psychological causes of these symptoms because it completely changes the course of treatment. In some reference books and articles, there are general protocols for managing psychotic patients (23). But in most of the previously written protocols, the management of a symptom such as aggression or agitation has been considered (24-26). Dr. Allen and his colleagues used the Delphi method and scoring pre-designed items by experts and collecting their comments in 2001 and 2005 (24, 27).
Gargia et al. drafted a protocol for patients with severe agitation using systematic review and then finalized it by Delphi method (28). Also, most of the existing protocols are related to patient management in the hospital emergency department, and less attention has been paid to earlier stages, such as the pre-hospital stage.
In developing this protocol, the goals of managing a patient with a psychiatric emergency before reaching the hospital were:
- Identifying and eliminating acute life-threatening risks as much as possible
- Psychiatric evaluation of patients in the crisis
- Identification of patients who have psychiatric symptoms with the physical origin and referring them to the appropriate center
- To stabilize patients with acute symptoms as soon as possible and prevent injury to themselves and others
- Less use of aggressive treatment, drugs, and mandatory treatments
- Establishing a therapeutic alliance with the patient, transferring the patient to a suitable place and starting the treatment process
In the current protocol, the first thing is the safety of technicians, their patients, and people who are in the scene. Almost all references related to acute psychotic symptoms consider the existence of a safe environment as the necessary precondition for patient management. These include the safety of the environment and the management of patients' behaviors that may be harmful to themselves and others. Therefore, this protocol, also predicting such behaviors and how to manage them according to international protocols, is considered.
Because of the legal aspects, police presence was also expected in the case of using mandatory treatments. This is also important for the safety of the technician, and it has been addressed in previous protocols (29). Also, considering the priority of saving patient’s life, early assessment of his/her vital signs is a priority (30) which we put in the primary steps of treatment. Because of the importance of diagnosing physical disorders that have symptoms similar to mental disorders, we placed making a differential diagnosis after examining vital signs.
Due to the confusion in the patient's condition and the potential lack of co-operation, attention should be paid to possible physical origins of symptoms. Because of the cultural norms in Iran, many patients live with their families, and the family is involved in the treatment process. The use of the capacity of families in the evaluation and taking the mental history of patients is emphasized (especially in cases that patients are unable or unwilling to participate). It is specifically addressed in our protocol. The protocol addresses cultural, spiritual, and religious issues. These issues can be not the same in different regions and affect the patient-technician relationship. These issues are along with the general spiritual principles of relationship with the patient (including empathy, complete acceptance, and being non-judgmental) (31).
In the current protocol, like previous ones, non-pharmacological management is preferred over pharmaceutical methods. Calming the patient without medication is the first priority, and drug therapy is the next priority. At the time of drug administration, in compliance with the general principles of pharmacological therapy, the priority is with the minimum dose and the oral administration root. Injectable drugs are the next priority. The goal of drug therapy is to calm agitated patients without decreasing their level of consciousness (32). However, based on available drugs and their side effects, and the possibility of drug abuse, we chose different types of drugs for the protocol. Lorazepam can be a useful drug, given the short time in the pre-hospital emergency and the need to calm the patient down with the least side effect. Lorazepam can be used in mild to moderate emergencies and in patients who are more cooperative (33).
Injectable benzodiazepines and antipsychotics such as olanzapine (considering its interaction with lorazepam and the possibility of cardiovascular collapse), ziprasidone and haloperidol are the last lines of treatment (17, 34, 35). The use of injectable midazolam as recommended in other protocols (36) was not approved by experts despite its rapid and practical effect on sedation, because of the risk of abuse. Other antipsychotics such as aripiprazole were not approved in previous protocols like our protocol and are not recommended (28). The use of physical restraint is proposed for patients who have not responded to primary treatments and may harm themselves and others.
In some protocols, special beds with certain height are recommended for physical restraint. Given that these beds do not exist in Iran, restraint with ordinary beds and wide and leather straps was recommended. Indications, safety recommendations, and limitations for using physical restraint in our protocol are consistent with other protocols. The use of physical restraint should be accompanied by chemical restraint (use of medication to calm the patient) (20, 21). Special attention for patients with delirium is similar to previous protocols (21).