30. self harm

Question 1

History suicide attempt

Answer 1

mental health
- event exploring: intention - end life or harm, triggers, impulsive or planned, note leaving, anything that made you hesitate?
- future risk exploring: how do you feel about it now? regret?
- next steps exploring: support, services, sectioning

physical health
- injury: timing, object used - rusty, tetanus? etc
- overdose : timing, strength and amount of drug, staggered? mixed overdose? what drugs are they normally on? OTC? alcohol involved?
- symptoms since: vomiting, black stool, abdo pain, colour of skin change, confusion, sob

MHx:
DHx: smoking, alcohol, recreational drugs? allergies, look out for any drugs that could be taken in overdose?
FHx:

Question 2

principles of different ways to manage overdose

Answer 2

Prevention of absorption
Activated charcoal

Active elimination
Haemodialysis for ethylene glycol, lithium, methanol, phenobarbital, salicylates, and sodium valproate;
Alkalinisation of the urine for salicylates.

Removal from the GI tract
Gastric lavage is rarely required; for substances that cannot be removed effectively by other means (e.g. iron), it should be considered only if a life-threatening amount has been ingested within the previous hour.

Question 3

ABCDE assessment overdose

Answer 3

ABCDE
A
Are they managing their airway?
B
Maintain airway, if RR low may need to bag-valve-mask
C
VBG, ABG if abnormal O2/RR
ECG !!!!
Maintain blood pressure with fluids
D
E
Temperature: hypothermia and hyperthermia

Examination
GI exam
Liver flap

Question 4

alcohol poisoning features

Answer 4

ataxia, nystagmus, dysarthria, drowsiness

Question 5

what are the risks associated with alcohol poisoning? management?

Answer 5

Risks: aspiration, hypotension, acidosis, coma, hypoglycaemia

Management:
Maintain clear airway
Monitor blood glucose and manage hypoglycemia if it occurs

Question 6

aspirin poisoning features

Answer 6

hyperventilation (resp compensation for acidosis), tinnitus, deafness, vasodilation and sweating

Question 7

risks and management aspirin poisoning

Answer 7

Risks: metabolic acidosis

Use plasma-salicylate concentration to guide management

Management:
Activated charcoal
Replace fluids and correct hypokalemia (important to correct before sodium bicarbonate)
IV sodium bicarbonate (urinary alkalinisation)
Haemolysis

Question 8

features paracetamol poisoning

Answer 8

First 24 hours: few or non-specific symptoms eg feeling tired, abdominal pain, or nausea

Next few days: absence of symptoms

4+ days: yellowish skin, blood clotting problems, and confusion occurs as a result of liver failure. Additional complications may include kidney failure, pancreatitis, low blood sugar, and lactic acidosis.

Question 9

estimating risk of severe liver damage from amount of paracetamol ingested

Answer 9

Less than 150 mg/kg - unlikely.
More than 250 mg/kg - likely.
More than 12 g total - potentially fatal.

Question 10

examination paracetamol overdose

Answer 10

GI exam

If ALF develops, the following may be seen: jaundice, hepatic flap, encephalopathy and tender hepatomegaly.

Question 11

define acute liver failure

Answer 11

elevated LFTs
coagulopathy (INR>1.5)
encephalopathy.

Without pre-existing cirrhosis. Illness course <26 weeks (except wilsons, reactivation of hep b, autoimmune hepatitis)

Question 12

what criteria do you use to grade hepatic encephalopathy

Answer 12

west haven criteria

Question 13

west haven criteria for heptic encephalopathy

Answer 13

grades:

1. Behaviour changes, altered sleep-wake cycle
2. Asterixis, lethargy, disorientation
3. More severe, somnolence COedema 25-35%
4. Coma, COedema 65-75%

Question 14

risk to brain liver failure

Answer 14

When the liver fails, ammonia levels increase→ astrocyte swelling → cerebral oedema → Intracranial Hypertension → herniation

Question 15

cerebral oedema in liver fialure, assessment and manageemnt

Answer 15

west haven criteria

Ammonia levels correlate with risk of ICH
<75 → rare
>100 → high grade hepatic encephalopathy
>200 → ICH

CT head
Elevate bed to 30 degrees
Net even fluid balance w CRRT
Allow for hyperventilation
Induce hypernatremia to 145-155 w NaCl 3% to reduce water into brain
Mannitol

Question 16

liver fialure and glucose

Answer 16

The liver stores glycogen and is the site of gluconeogenesis

When the liver fails, this leads to hypoglycemia

Question 17

liver failure and coagulation

Answer 17

The liver synthesises clotting factors and anticoagulants
When the liver fails, increased risk of bleeding and of clotting

Question 18

liver failure and immunity

Answer 18

The liver decreases risk of infection and kupffer cell → innate immunity
Have a low threshold for empirical abx

Question 19

how does paracetamol overdose and liver fialure lead to metabolic acidosis

Answer 19

NAPQI inhibits aerobic metabolism → anaerobic metabolism → lactic acidosis

Acute liver failure → failure to metabolise lactate → lactic acidosis

Shock → hypoperfusion → lactic acidosis

Question 20

investigations paracetamol overdose

Answer 20

• U&E
• LFT
• clotting
• ABG for acisosis
• monitor glucose hourly (capillary glucose measurement)
• paracetamol level

Question 21

when should you take paracetamol level

Answer 21

Paracetamol level: take paracetamol level four hours post-ingestion, or as soon as the patient arrives if:

Time of overdose is greater than four hours.

Staggered overdose (in staggered overdoses, the level is not interpretable except to confirm ingestion).

Question 22

Management paracetamol overdose if presenting within 1 hour of ingestion

Answer 22

1. Activated charcoal

Question 23

Management paracetamol overdose if presenting after 1 hour of ingetsing paracetamol

Answer 23

1. Check level of paracetamol in the blood at or after 4 hours
   + Commence acetyl cysteine if above treatment line or if it is more than 8 hours after they ingested > 150 mg/kg

Question 24

management of paracetamol overdose - staggered overdose

Answer 24

Commence acetyl-cysteine

Question 25

management of paracetamol overdose if presenting >24 hours after ingestion

Answer 25

Check all markers and talk to toxicology If paracetamol detected OR INR >1.3 OR ALT > 2x normal then commence acetyl-cysteine

Question 26

referring to other teams paracetamol overdose

Answer 26

Refer to ICU if there is fulminant liver failure - those treated with N-acetylcysteine (NAC) to the medical team and all para-suicides to the psychiatric team.

Question 27

N-acetylcysteine infusions

Answer 27

First infusion: initial loading dose of 150 mg/kg body weight over 1 hour. Second infusion: 50 mg/kg over the next 4 hours. Third infusion: 100 mg/kg over the next 16 hours. The patient should receive a total dose of 300 mg/kg body weight over a 21-hour period. A ceiling weight of 110 kg should be used when calculating the dose for obese patients.

Question 28

contraindictaions to n-acetylcystine

Answer 28

There are now no specific contra-indications to acetylcysteine use. Even if there is a previously reported reaction, the benefits of treatment outweigh the risks.

Question 29

efficacy of n-acetylcystine

Answer 29

It is virtually 100% effective in preventing liver damage when given within eight hours of ingestion[7]. After eight hours, efficacy decreases sharply.

Question 30

management of paracetamol overdose during pregnancy

Answer 30

NAC appears to be safe during pregnancy and therefore should be administered.

Question 31

what criteria is used for liver transplant in paracetamol induced acute liver failure

Answer 31

King's College Hospital criteria

Question 32

King's College Hospital criteria for liver transplantation in paracetamol-induced acute liver failure

Answer 32

Arterial pH <7.3 or arterial lactate >3.0 mmol/L after adequate fluid resuscitation; OR If all three of the following occur in a 24-hour period: Creatinine >300 μmol/L. PT >100 seconds (INR >6.5). Grade III/IV encephalopathy. Strongly consider transplantation if: Arterial lactate >3.5 mmol/L after early fluid resuscitation.

Question 33

features of opioid overdose

Answer 33

pinpoint pupils. unconsciousness. difficulties with breathing.

Question 34

management opioid overdose

Answer 34

IV or IM naloxone : Rapid onset and short half life so need more than one dose often 1. Initially 400 micrograms then 800 micrograms for up to 2 doses at 1-minute intervals 2. if no response to preceding dose, then increased to 2 mg for 1 dose 3. if still no response (4 mg dose may be required in seriously poisoned patients)

Question 35

features seretonin syndrome

Answer 35

Neuromuscular excitation hyperreflexia myoclonus rigidity nystagmus autonomic nervous system excitation hyperthermia sweating dilated pupils altered mental state Confusion

Question 36

management seretonin syndrome

Answer 36

supportive including IV fluids benzodiazepines more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine

Question 37

pupils SS vs NMS

Answer 37

SS - dilated NMS - normal pupils

Question 38

neuro exam SS vs NMS

Answer 38

SS - hyperreflexia, clonus NMS - hyporeflexia, lead pipe rigidity

Question 39

when does neuroleptic malignant syndrome occur

Answer 39

drug reaction to starting antipsychotics It may also occur with dopaminergic drugs (such as levodopa) for Parkinson's disease, usually when the drug is suddenly stopped or the dose reduced.

Question 40

features of NMS

Answer 40

Neuro - muscle rigidity - hyporeflexia - normal pupils autonomic nervous system - HTN - tachycardia - tachypnoea mental state - agitated delirium with confusion

Question 41

what blood test might help you differentiate SS and NMS

Answer 41

raised creatine kinase in NMS

Question 42

complications of NMS

Answer 42

Acute kidney injury (secondary to rhabdomyolysis) may develop in severe cases. A leukocytosis may also be seen

Question 43

management of NMS

Answer 43

1. stop antipsychotic 2. transfer to medical ward - may be ICU + IV fluids to prevent renal failure + dantrolene may be useful in selected cases + bromocriptine, dopamine agonist, may also be used

Question 44

features of tricyclic overdose?

Answer 44

Early features relate to anticholinergic properties: dry mouth, dilated pupils, agitation, sinus tachycardia, blurred vision. Features of severe poisoning include: arrhythmias seizures metabolic acidosis coma

Question 45

ecg changes in tricyclic overdose

Answer 45

ECG changes include: sinus tachycardia widening of QRS prolongation of QT interval Widening of QRS > 100ms is associated with an increased risk of seizures whilst QRS > 160ms is associated with ventricular arrhythmias

Question 46

what does the ecg in tricyclic overdose mean in terms of complications

Answer 46

Widening of QRS > 100ms is associated with an increased risk of seizures QRS > 160ms is associated with ventricular arrhythmias

Question 47

management of tricyclic overdose

Answer 47

IV bicarbonate - first-line therapy for hypotension or arrhythmias - indications include widening of the QRS interval >100 msec or a ventricular arrhythmia + other drugs for arrhythmias

Question 48

presentation of alcohol withdrawal

Answer 48

6-12 hours : minor alcohol withdrawal symptoms: tremor, anxiety, headache. subside by 40-50 hours 12-24 hours alcoholic hallucinosis (auditory and visual, frightening, may last 5-6 days) 12-48 hours seizures 48-72 hours delirium tremens : coarse tremor, agitation, fever, tachycardia, profound confusion, delusions, hallucinations

Question 49

what score should you use to assess alcohol withdrawal

Answer 49

clinical institute withdrawal assessment tool (CIWA) Patients with scores ≤8 typically do not require medication for withdrawal.

Question 50

implication of delirium tremems not being treated

Answer 50

hyperpyrexia, ketoacidosis and profound circulatory collapse

Question 51

management of delirium tremems

Answer 51

Treatment of delirium tremens/alcohol withdrawal Chlordiazepoxide or diazepam (long acting benzos) Lorazepam may be preferable in patients with hepatic failure

Question 52

presentation of opioid withdrawal

Answer 52

flu-like manner (runny nose, eyes) GI upset (abdo pain, diarrhoea) Sympathetic hyperactivity (tachycardia and hypertension, dialted pupils, sweating, goose bump skin) central nervous system (CNS) stimulation

Question 53

management of opioid dependence

Answer 53

specialist drug dependence clinics maintenance therapy or detoxification 1. methadone or buprenorphine as first line for opioid detox Compliance monitored urine urinalysis detox should normally last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in community

Question 54

methadone vs buprenorphine

Answer 54

methadone is a full agonist of the mu-opioid receptor - binds to these receptors in the brain and fully activates them. This action can relieve withdrawal symptoms and cravings. Has a long half-life buprenorphine is a partial agonist of the mu-opioid receptor. It binds to the mu-opioid receptors in the brain but only partially activates them. This partial activation is enough to alleviate cravings and withdrawal symptoms in individuals with opioid dependence. Furthermore, the binding of buprenorphine to the mu-opioid receptor is very strong, or 'high affinity,' meaning it can displace other opioids from these receptors and prevent them from exerting their effects. SAFER PROBLEM IF YOU USE ALONGSIDE

Question 55

questions to screen for alcohol missuse/dependence

Answer 55

For alcohol use CAGE (Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers). Ask “Have you ever: (1) felt the need to cut down your drinking; (2) felt annoyed by criticism of your drinking; (3) had guilty feelings about drinking; and (4) taken a morning eye opener?”

Question 56

Pharmacological management of alcohol dependence

Answer 56

disulfiram - promotes abstinence acamprosate - reduces craving SIGN recommends alcoholic patients should receive oral thiamine if their 'diet may be deficient'

Question 57

disulfiram - pharmacology? patient inofrmation, contraindications

Answer 57

promotes abstinence - alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase. Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms. Contraindications include ischaemic heart disease and psychosis

Question 58

acamprosate - pharamcology

Answer 58

reduces craving, known to be a weak antagonist of NMDA receptors, improves abstinence in placebo controlled trials

Question 59

harm reduction interventions opioid missuse

Answer 59

needle exchange Offering HIV, Hep B and C screening

Question 60

complications of opioid misuse- IV drug use

Answer 60

Overdose - respiratory depression Infection - viral infection secondary to sharing needles : HIV, hep B&C - Bacterial infection secondary to injection : infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis - cellulitis - abscesses - ulcers Blood clots - Venous thromboembolism Psychosocial impact - craving, interfere with daily life, financial --> crime, prostitution, homelessness

Question 61

diagnosis of anorexia nervosa DSM-5

Answer 61

1. restriction of energy intake --> impact 2. intense fear of gaining weight 3. disturbance in the way in which one's body weight or shape is experienced

Question 62

physiological changes anorexia nervosa

Answer 62

Most things low BMI Bradycardia Hypotension Potassium FSH, LH Oestrogen and testosterone G&C raised Growth hormone Glucose Salivary Glands Cortisol Cholesterol Carotenemia

Question 63

management anorexia

Answer 63

adults one of: - individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) - Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) - specialist supportive clinical management (SSCM). children 1. 'anorexia focused family therapy' 2. CBT

Question 64

prognosis of anorexia nervosa

Answer 64

Up to 10% of patients will eventually die because of the disorder.

Question 65

complications of anorexia nervosa

Answer 65

- refeeding syndrome -> cardiac failure - peripheral oedema secondary to RFS - anaemia - electrolyte : hypophosphatemia, hypomagnesemia - acute thiamine deficiency - hypothyroid - more at risk of liver failure following paracetamol overdose

Question 66

DSM-5 bulimia nervosa

Answer 66

1. recurrent episoses of binge eating with a sense of lack of control during 2. recurrent inappropriate compensatory behaviour in order to prevent weight gain 3. the binge eating and compensatory behaviours both occur, on average, at least once a week for three months.

Question 67

management bulimia nervosa

Answer 67

ref for specialist care adults 1. bulimia-nervosa-focused guided self-help 2. eating-disorder-focused cognitive behavioural therapy (CBT-ED) children 1. children should be offered bulimia-nervosa-focused family therapy (FT-BN)

Question 68

electrolytes re-feeding

Answer 68

KPMG The metabolic consequences include: Hypophosphatemia Hypokalaemia Hypomagnesaemia Abnormal fluid balance These abnormalities can lead to organ failure.

Question 69

managing re-feeding if not eaten for > 5 days

Answer 69

If patient not eaten for > 5 days, aim to re-feed at < 50% energy and protein levels

Question 70

management of re-feeding

Answer 70

Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days Start immediately before and during feeding: oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium (0.2-0.4 mmol/kg/day)

Question 71

risk factors for re-feeding

Answer 71

BMI < 16 kg/m2 Unintentional weight loss >15% over 3-6 months Little nutritional intake > 10 days Hypokalaemia, Hypophosphatemia or hypomagnesaemia prior to feeding (unless high)

Question 72

factors which increase risk of suicide

Answer 72

male sex (hazard ratio (HR) approximately 2.0) history of deliberate self-harm (HR 1.7) alcohol or drug misuse (HR 1.6) history of mental illness depression schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide history of chronic disease advancing age unemployment or social isolation/living alone being unmarried, divorced or widowed

Question 73

Features associated with an increased risk of completed suicide at a future date

Answer 73

efforts to avoid discovery planning leaving a written note final acts such as sorting out finances violent method

Question 74

protective features suicide

Answer 74

family support having children at home religious belief

Question 75

causes seretonin syndrome

Answer 75

antidepressants: SSRI, SNRI, TCA, MAOI Drugs causing SS esp when interacting with others: - lithium - tramadol, pethidine - St John's Wort recreational: - ecstasy - amphetamines