A medical emergency is a condition that poses a threat to the patient’s life and therefore requires urgent measures to diagnose, treat and determine the further tactics of patient management.
This definition of a medical emergency only refers to an immediate life-threatening condition of the patient. In clinical practice, the concept of “urgent” is interpreted more broadly and also includes many pathological processes that do not pose an immediate threat to life but can quickly lead to a significant deterioration in the condition or are extremely painful for the patient, as well as situations requiring urgent diagnostic procedures for exclusion of severe acute pathology.
The concept of a “mental health emergency” is conditional since there is practically not a single emergency condition that would be accompanied by a violation of only mental functions and would not involve other body systems. In a number of guidelines, this group includes emergencies that develop only within the framework of mental illness, alcoholism, drug addiction and substance abuse and exclude acute mental disorders in case of somatic diseases. In practical medicine, a broader interpretation is used, according to which all emergency conditions, regardless of their nosological affiliation accompanied by severe mental disorders should be referred to as a “mental health emergency”. This is the definition used in this tutorial.
Thus, it is possible to distinguish several fundamentally different groups of urgent conditions occurring with severe mental disorders:
- Emergency conditions that develop in the course of mental illness proper (for example: suicidal actions in melancholic depression);
- Emergency conditions developing in the framework of alcoholism, drug addiction and substance abuse (for example: alcoholic delirium, heroin overdose);
- Urgent somatic conditions occurring with the addition of severe mental disorders (for example: somatogenic delirium in peritonitis);
- Emergencies that develop as complications (adverse events) with the planned use of psychotropic drugs in psychiatric and somatic practice (for example: acute dystonia, serotonin syndrome).
The main feature of all of the above emergencies is a combination of severe mental and somatic disorders, which requires the doctor providing assistance to have sufficient knowledge of both psychiatry and other branches of medicine (therapy, neurology, surgery, etc.). Doctors of emergency care and doctors of somatic hospitals in most cases have to deal with urgent somatic conditions occurring with severe mental disorders and emergencies with alcoholism and drug addiction.
Mental health: tactics of first aid for emergency conditions
The tactics of medical care in a mental health emergency depends on the severity of the patient’s condition and the conditions for the provision of care:
- If necessary, resuscitation measures should be carried out urgently. Often, acute mental disorders accompany a serious destabilization of the somatic state and precede the development of clinical death (for example: psychomotor agitation against the background of increasing respiratory failure);
- If the patient needs emergency therapeutic, surgical, toxicological care, it should be provided, first of all, in the prescribed volume. Even pronounced mental disorders are not grounds for refusing a patient with emergency somatic care;
- If mental disorders (usually psychomotor agitation) interfere with emergency diagnostic and therapeutic manipulations, their relief should be carried out by a doctor providing emergency care;
- After performing all the necessary emergency diagnostic and therapeutic manipulations, if mental disorders persist, the patient should be examined by a psychiatrist: in a general hospital – if there is a full-time consultant psychiatrist, he or she should be called for consultation and examination of the patient; outside the hospital (at home, on the street, in an outpatient facility, at an enterprise, in a public place) or in a hospital in the absence of a consultant psychiatrist – calling the emergency psychiatric team.
Currently, most multidisciplinary somatic hospitals have full-time consultant psychiatrists. The duties of a psychiatrist-consultant include: diagnosing a mental disorder, choosing treatment for the patient, prescribing psychopharmacotherapy and monitoring its implementation if the patient continues treatment within the walls of a somatic hospital.
An ambulance for psychiatric care travels to public places, to enterprises and organizations, to the street, to apartments, to medical institutions. Calls are accepted from medical workers, police officers, heads of enterprises and organizations (in the absence of medical workers) and direct relatives of the patient. When a psychotic state develops on the street or in a public place, police officers should be called. Calls to apartments are accepted from direct relatives of the patient or from neighbors in the absence of direct relatives. Calls from unauthorized persons are accepted only in case of socially dangerous actions of the patient.
A psychiatric ambulance cannot be used for routine consultations of patients with mental disorders in somatic hospitals. This function is assigned to the psychiatrist-consultant of the hospital or is provided by the psychiatrists of the district neuropsychiatric dispensary.
Thus, the immediate provision of emergency care and the establishment of a syndromic diagnosis is the responsibility of the attending (duty) doctor of a somatic hospital. The psychiatrist joins the provision of emergency care only in the future, he or she is responsible for making a nosological diagnosis and determining the place of treatment for the patient. If the patient continues treatment in a somatic hospital – a psychiatrist – a consultant prescribes treatment and monitors its implementation. The decision to transfer or hospitalize a patient with mental disorders to a psychiatric hospital (psychosomatic department) can only be made by a psychiatrist.
The place of treatment is determined by the patient’s condition:
- If mental disorders accompanying a somatic illness can be stopped directly in a hospital or they do not interfere with being in the department – the patient continues treatment in a somatic hospital (for example: a combination of alcohol withdrawal syndrome with exacerbation of chronic pancreatitis – therapy is carried out by the patient’s attending physician with the participation of a psychiatrist;
- Patients with mental disorders are transferred (hospitalized) to a psychiatric hospital, whose somatic pathology does not determine the severity of the condition and does not require being in a somatic hospital (for example: a patient suffering from melancholic depression inflicted superficial self-cuts in the forearm; after the initial surgical treatment of the wound and suture, he or she should be transferred to a psychiatric hospital);
- When a severe somatic pathology is combined with severe mental disorders that prevent being in a regular somatic department, patients are transferred (hospitalized) to a specialized psychosomatic (somatopsychiatric) department (for example: a patient has a combination of manic syndrome with an open fracture of the leg bones – after performing an operation, the patient continues treatment in the psychosomatic department);
- If the clinical picture is dominated by a severe somatic condition or it threatens the patient’s life, the patient continues treatment in a somatic hospital (intensive care unit) under the supervision of a full-time consultant psychiatrist (for example: delirium against the background of peritonitis – treatment is carried out in the intensive care unit).
It is strictly forbidden to leave a patient with severe mental disorders under the supervision of roommates, relatives, hospital security personnel. The patient should be monitored by a doctor or nurse.
In the event of aggressive actions of a patient with mental disorders (immediate danger to others), police officers may be involved to provide assistance.
Mental health conditions that require urgent help
- Psychomotor agitation;
- Suicidal and auto-aggressive behavior;
- Seizures and status epilepticus;
- Non-alcoholic (somatogenic) delirium;
- Amentive syndrome;
- Alcoholic delirium (complicated and uncomplicated);
- Gaie-Wernicke acute alcoholic encephalopathy;
- Consciousness shutdown syndromes;
- Refusal to eat due to mental health problems;
- Heavy alcohol intoxication;
- Opiate or opioid overdose;
- Withdrawal symptoms;
- Panic attacks and vegetative crises;
- Poisoning with psychotropic drugs;
- Acute complications with the use of psychotropic drugs.