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 (15).
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 (25). But in most of the previously written protocols, the management of a symptom such as aggression or agitation has been considered (24-27). Allen, et al. recommended different pharmacological and behavioral interventions inpatient with agitation in different situations (24, 28).
Gargia et al. suggested several recommendations on the assessment of agitation emphasize the importance of identifying any possible medical cause (29). 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 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 (15-16). 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 (30). Also, considering the priority of saving a patient’s life, early assessment of his/her vital signs is a priority (31) 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.
The second point in the present protocol is to consider the overlap of many symptoms of physical illness with psychiatric disorders and to consider the differential diagnosis. Therefore, vital signs and evidence of life-threatening disorders should be examined. Impairment of the judgment and lack of co-operation in psychiatric patients can worsen the situation. Given the cultural conditions in Iran
In the majority of patients' cases, living with families and intervention of families in the process of the treatment, utilizing the capacity of families in the evaluation of the patient can be very helpful, which is highly considered in the present protocol. Also, in addition to the common spiritual principles associated with each patient (such as empathy, complete acceptance
and being non-judgmental, etc) paying attention to the specific religious and spiritual cultures and areas of each region that affect the therapeutic relationship with the patients is of great importance (32).
In the current protocol, like previous ones, non-pharmacological management is preferred over pharmaceutical methods. Calming the patient without medication is the 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 (29). The goal of drug therapy is to calm agitated patients without decreasing their level of consciousness (33). 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 (34).
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 (19, 35, 36). The use of injectable midazolam as recommended in other protocols (37) 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 (29). 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) (22, 23). Special attention for patients with delirium is similar to previous protocols (23).
Study limitations
The study has several limitations. Firstly, a systematic review of the study has not been conducted and only a review of existing articles was undertaken. And secondly, Due to the limited availability of medicines in the emergency room of Iran, the suggested treatments may not necessarily be the best choices.