[The situation of emergency psychiatry in Germany]. / Zur Situation der Notfall- und Akutpsychiatrie in Deutschland.

The impact of psychiatric emergencies for the care of patients in preclinical emergency medicine, in emergency departments and in psychiatric hospitals has been underestimated for a long time. There is still insufficient knowledge and a need for further research. There are, however, sufficient reasons to assume that annually approximately 500,000 patients with a psychiatric emergency receive treatment from a preclinical emergency physician and another 1.5 million in emergency departments in Germany. Further, approximately 500,000 patients are admitted to psychiatric hospitals as an emergency. The most frequent reasons are intoxication, agitation, aggressiveness and suicidal ideation, posing a threat of self-harm to the patient or to other persons and evoking other life-threatening conditions. Emergency psychiatry also plays a role in collective injuries, such as mass disasters, catastrophes and rampage situations. There is some evidence that the number of psychiatric emergencies is increasing. Reasons are, among others, changes in the services provided for inpatient and outpatient treatment, a reduction in stabilizing psychosocial factors and a general increase in the utilization of emergency healthcare services.

[Psychotropic agents in emergency medicine]. / Psychopharmaka im Notarztdienst.

The aim of these two CME articles Psychotropic agents in emergency medicine and Psychopharmacotherapy in emergency medicine is to give an overview of drugs and their indications in the context of emergency psychiatry. Most relevant for prehospital care are benzodiazepines and antipsychotics, like lorazepam, diazepam, and haloperidol. But even newer antipsychotics could be suitable for emergency medicine. The efficacy of some of the newer antipsychotics, so-called atypical antipsychotics, has been studied in emergency psychiatric departments. The evidence whether these drugs provide the required efficacy, universality and safety profile in emergency medicine, in comparison to, for example, haloperidol, is presented in the following article.

[Psychopharmacotherapy in emergency medicine]. / Psychopharmakotherapie im Notarztdienst.

Part two of the CME article Psychotropic agents and psychopharmacotherapy in emergency medicine aims to give an understanding of the pharmacotherapy of psychiatric disorders in emergency medicine. In contrast to somatic emergencies, many emergency physicians are not familiar with the treatment of psychiatric emergencies, although there are guidelines and recommendations. In the following article, treatment recommendations for the 5 most common and relevant syndromes in emergency medicine (i.e., suicide, delirium, agitation, stupor, and syndromes due to psychopharmaceutical use) are described based on the German S2-Guideline Emergency Psychiatry that will be published soon.

[Suicidality: procedure in emergency cases]. / Suizidalität: Procedere im Notfall.

Emergency physicians (EP), paramedics and the staff of the emergency room play an increasingly important role in the medical and psychological emergency treatment of patients after suicide attempts, as well as in the crisis intervention of persons with acute suicidal tendencies. This article aims to give an overview of the prevalence rates, methods of suicide or attempted suicide and the problems faced by EPs when treating these patients. In addition, concepts are presented which allow an adequate risk assessment of suicidality and the options for primary crisis intervention. Paramedics and intensive care clinicians are increasingly confronted with this complex process with social, personal and medical aspects. In order to treat people in suicidal crises and/or after a suicide attempt and to provide a safe and optimal care for this often heterogeneous group of patients, clear guidelines are a prerequisite. The first assessment of the acute danger of suicide is of particular importance due to the resulting consequences and a clear approach is demonstrated for dealing with suicidal people. Furthermore, the legal principles are presented.

[Psychiatric care in emergency departments]. / Psychiatrische Versorgung in der Notaufnahme.

BACKGROUND: Psychiatric emergency situations (PES) are frequent in emergency departments (EDs). There are, however, only few investigations that focus on the prevalence of these patients or on diagnostic and therapeutic standards. These PESs in EDs should be treated according to standards comparable to medically disabled patients. Thus it is necessary to learn more about the diagnostic and therapeutic possibilities in EDs, about the procedures and the decision-making process whether these patients are transferred to further outpatient or inpatient treatment. MATERIALS AND METHODS: A survey was conducted in EDs throughout Germany and 1,073 were contacted and asked to participate. The questionnaire consisted of questions concerning the size of the ED and of the hospital (e.g. number of patients and physicians), the prevalence of psychiatric disorders, the diagnostic and therapeutic possibilities, standard procedures for dealing with PES and the method of care in six typical case reports. RESULTS: A total of 74 EDs participated (76% interdisciplinary EDs) with an average of 22,827 ± 12,303 patients per year in the ED. Psychiatry as a medical discipline was integrated into 10 EDs (14%) and psychiatric competence could be activated in 84% of EDs. Participating EDs reported prevalence rates of 15% mentally disordered patients and 9% of patients who required psychiatric diagnostic and therapeutic procedures. Of the patients 2% presented after suicide attempts and 3% were considered to be aggressive. Approximately 50% of all PESs were related to substance abuse disorders. An average of 2.5 ± 4.2 (range 0-25) members of the medical and nursing staff were injured during a 1-year period by violent patients. Legal actions against the will of patients were initiated in 81% of EDs. Standardized diagnostic screening instruments or self-rating questionnaires were used in only four EDs. As standard procedures for the diagnostic work-up of psychiatric patients (medical clearance) physical examination, measurement of heart rate and blood pressure and conducting of some laboratory tests (glucose, blood cell count, electrolytes and renal function) were named. Diazepam (91%), lorazepam (88%) and haloperidol (87%) were considered to be indispensable psychopharmacological agents in the ED. CONCLUSIONS: In the majority of participating EDs, diagnostic standards for PES were known but were not routinely applied. It has to be assumed that many psychiatric disorders, in particular suicide attempts and suicidal ideation are not discovered. In many EDs psychiatric knowledge was available but a psychiatric consultation was only rarely requested. Physicians in the ED report a high degree of legal uncertainty with psychiatric patients. The use of screening instruments is recommended.

[Necessity for treatment of psychiatric emergencies in the emergency medical service. Evaluation of the "indicator for psychiatric pharmacotherapy"]. / Behandlungsbedürftigkeit psychiatrischer Notfälle im Notarztdienst. Evaluierung des "Indikator für psychiatrische Pharmakotherapie"

BACKGROUND: Psychiatric emergency situations (PES) are common in the physician-based emergency medical system (EMS) in Germany. However, many emergency physicians (EP) feel insecure in assessing the necessity for treatment of these patients. The aim of this investigation was to evaluate whether a short, newly developed questionnaire (Indicator for Psychiatric Pharmacotherapy, IPP) is able to help EPs in deciding for or against pharmacological treatment. PATIENTS AND METHODS: The protocols of the EMS at the Saarland University Hospital were prospectively collected over a 1-year period and PESs were identified and analyzed in detail. The 7-item IPP, which focuses on the most relevant psychiatric symptoms, was to be completed for each PES. RESULTS: Among all calls for an EP (2,114) 250 (11.8%) were classified as a PES. The most frequent diagnoses were alcoholic intoxication, state of agitation and suicide attempts. Of the IPP questionnaires 193 could be evaluated and in 31.2% of all PESs a specific psychiatric medication was administered. These patients scored significantly higher in the IPP compared to those who did not receive medication (8.0 ± 3.9 compared to 5.6 ± 3.2, p < 0.001). The IPP items "anxiety", "agitation/aggression", "mood" and "physical symptoms/disorders" had the highest impact on the administration of psychotherapeutic drugs. DISCUSSION: The IPP can be a valuable tool to assess the necessity of pharmacological treatment for patients in PESs. The assessment of the symptom categories "anxiety", "agitation/aggression", "mood" and "physical symptoms/disorders" seems to be sufficient to estimate a need for treatment.