Based on the findings from the literature review and discussed issues in the expert panel, important topics for managing psychiatric patients were categorized in three levels: 1) Patient safety and security issues, 2) Patient status assessment and diagnosis and 3) Patient management (medical, behavioral management, and referral to a treatment center).
The first step is to ensure the safety of the patient, technicians, and people on the scene (15). This stage includes: a) pre-scene assessments of site security, escape routes, and safe locations in the event of violence from the patient, b) assessment of patient’s access to weapons and equipment that could threaten his/her own life, technicians or attendees (16), C) Assessment for risk and need for back up and the presence of police, which includes anticipating their entrance method and avoidance of entering the place alone, D) using family capacities to provide security (16) and E) Assessment of risk factors for violence and predicting it Symptoms of imminent aggression include: 1)Motor restlessness and agitation, 2) The loud and threatening tone of voice, 3) Threatening behavior and gestures, 4) Verbal Threats, 5) Staring and angry face mode, 6) Sudden behaviors (He throws the object in his hand suddenly), 7) Bizarre behavior due to delusion and hallucination.
Patient evaluation includes the following: A) Urgent physical needs by evaluating vital signs (Airway, presence of respiratory distress, and pulse), B) Obtaining a targeted mental health history of the patient from his or her family including: Demographic characteristics (sex, age, occupation), history of psychiatric illness, history of physical and primarily neurological diseases, history of drug abuse, history of violence or suicide (15), C) Differential diagnoses (psychological causes versus physical causes of symptoms) and physical risk factors (sudden onset of symptoms without previous history, age younger than 12 years and older than 60 years, known neurological diseases such as seizures or dementia, existence of neurological symptoms such as ataxia, nystagmus and complex drug regimen (Table 2) (17) D) Considering cultural and spiritual aspects of patients which can effect on symptoms and how to help them.
Patient management includes: a) behavioral management, b) pharmacological management, c) patient family management.
a) Patients’ behavioral management includes following recommendations on how to behave and speak to the patient:
- Speak to the patient in a calm, measured and confident tone
- Reduce external stimuli, such as the noise and the provocative behavior of others (18)
- Reduce internal triggers like hunger and thirst, and offer water and food to the patient whenever possible.
- have empathic and non-judgmental attitudes and behaviors
- accept the patient's hallucinations and delusions appropriately
- Don't make a false promise to the patient
- Use short, simple sentences and repeat the sentences if necessary
- Listen to the patient
- Use patients’ words as much as possible
- Reassure the patient that you understand the problem
- Encourage the patient to provide information to those who can help
- Attempt to meet the patient's spiritual needs (include general spiritual principles in the patient-therapist relationship, showing compassion and unconditional acceptance to the patient)
- Encourage the patient to provide information to those who can assist him/her.
In case of aggression, in addition to the mentioned points, Keep the patient at least 2 meters away, tell the patient that aggression is unacceptable, offer medication and in order to prevent harm themselves or others, use physical restraint if s/he continues (19).
b) Pharmacological management: There are several important principles to consider in drug administration. The aim of emergency medical treatment should be to calm down the agitated patient as quickly as possible without reducing the patient's level of consciousness. Like all emergencies, oral drugs are preferred to injectable ones. The drug should be selected based on the onset of action and availability. Short-acting drugs are preferred over long-acting drugs. Medicines with fewer side effects are also preferred. Thus, in the first step, oral medications such as benzodiazepines or lorazepam with or without typical antipsychotics such as risperidone may be used.
In the second line, other antipsychotics such as haloperidol may be administered. If the patient’s condition does not improve or he/she does not cooperate in the treatment, intramuscular antipsychotics such as Amp haloperidol 5mg along can be used. If necessary, these medications can be repeated with cardiac and blood pressure monitoring. Other medicines such as promethazine or injectable benzodiazepines may also be used to increase the effectiveness of the administered drugs (19-21) (table 3).
Restraints may use with the pharmacological methods. This treatment option is used as the last choice in patients who are uncooperative and physically dangerous and may harm themselves or others, and when non-pharmacological and primary pharmacological methods are ineffective. In these cases, special care should be taken to protect the patient from life-threatening situations (Table 4).
In addition to the above-mentioned points, consider the Contraindications of restraining which include the followings (22, 23):
- Cases in which patients used Phencyclidine (PCP) based on the family history
- Patients with recent surgery in the eye or central nervous system (Because of an increase in intra-cerebral or intraocular pressure)
- patients with a low level of consciousness or with delirium
c) Intervention in the patient family including having empathy and understanding of the critical situations and psycho-education about the conditions and places that they can attend (24).
Management of suicide emergencies requires special consideration. The expert panel suggests that suicide emergencies need a separate protocol. Moreover, while drug and alcohol poisoning and deprivation have similar symptoms with psychological emergencies, they have a completely different treatment, and they need another protocol.