4 - PSY - Emergencies

Question 1

Major PSY emergencies

Answer 1

suicidal patients

agitated and violent patients

Question 2

Minor PSY emergencies

Answer 2

Grief reaction
rape
disaster
panic attacks

Question 3

Medical emergencies in PSY

Answer 3

Delirium
Neuroleptic Malignant Syndrome
Serotonin  syndrome
Overdose of common PSY med
OD + Withdrawal from addictive substance

Question 4

Delirium - what is it

Answer 4

transient, potentially reversible cerebral dysfunction that has acute or sub-acute onset - manifests as fluctuation mental status abnormaltities
common and potentially lethal

Question 5

Delirium Clinical Features

Answer 5

Abrupt onset
Fluctuating course
Clouding of consciousness
Disturbed cognition
\+2 more from lists

Question 6

Types of delirium

Answer 6

Hyperactive - increased arousal - restless, agitated or aggressive
Hypoactive - withdrawn, quiet and sleepy
Mixed
Delirium superimposed on dementia
Persistent delirium

Question 7

Delirium Assessement

Answer 7

Hx - may need collateral
Physical exam + Ix
Risk assessment
Cognitive examination eg MoCA

Question 8

Ix for Delirium - what are you looking for?

Answer 8

Infection
Medications
Metabolic/endocrine
Neurological
Others - hypoxia, cardiac

Question 9

Delirium management

Answer 9

• ID and treat cause
• calm environment
• involve family/carers
• consider PSY referral
• Avoid sedation unless severely agitated
• review pt regularly

Question 10

Causes of an Acute Behavioural Disturbance

Answer 10

directly due to psychotic Sx like delusions
non-psychotic Sx - high anxiety/arousal levels
Illicit substances use

Question 11

Basic principles in managing an Acute Behavioural Distrurbance

Answer 11

Predictions of risk of agitation
Prevention of escalation of behaviour
Intervene to ensure patient and staff safety

Question 12

What to look for in MSE of Acute Behavioural Disturbance - increase risk of aggression..

Answer 12

-persecutory delusions
passivity delusions
threats of violence
emotions congruent with violence
agitated behaviour
limited insight

Question 13

Rapid Tranquilization - aim?

Answer 13

calm agitated patient without sedating them, and reduce risk of violence and harm

Question 14

Rapid Tranquilization - drugs used? considerations? The perfect drug?

Answer 14

Benzos - lorazepam/midazolam
AP’s - haloperidol/olanzapine (agitation)
combination of above
Promethazine

Give orally whenever possible, always consult senior doctor, use minimum dose

Rapid onset, Short acting, Minimal SE’s and easily reversible effects

Question 15

Neuroleptic Malignant Syndrome - risk factors

Answer 15

• NMS previous, alcoholism, brain damage
• Agitation, over activity, catatonia
• Dehydration
• Many treatment related factors to do with Antipsychotics

Question 16

NMS - Sx

Answer 16

variable presentation

• fever, sweating, rigidity, confusion, fluctuating consciousness
• autonomic instability > ~BP, ^HR, sweating, salivation, incontinence

Question 17

NMS - Ix

Answer 17

no blood tests pathognomonic of NMS
CK is frequently raised (>1000)
Deranged LFTS and leucocytosis

Question 18

NMS - Tx

Answer 18

Stop AP
Monitor obs
consider benzo for sedation
rehydration

Question 19

Acute dystonia - what is it?

Answer 19

reversible extrapyramidal SE after admin of AP meds
muscle spasm anywhere in body
significant distress - life threatening if laryngeal muscles
High potency D2 receptor meds like HALOPERIDOL most likely to cause it

Question 20

Acute dystonia - treatment

Answer 20

Usually responds to anticholinergic meds - Procyclidine

Question 21

Lithium toxicity - lithium excretion? why check blood levels regularly? how regularly? when are blood levels usually done? when is clearance reduced?

Answer 21

• almost fully renal excretion
• very narrow therapeutic window
• weekly then once every 3 months
• usually 12h after last dose
• reduced clearance if renal impairment

Question 22

Which medications raise serum lithium and should be ideally avoided?

Answer 22

Diuretics (esp thiazides) NSAIDS, ACEi

Question 23

Treatment for lithium toxicity

Answer 23

prevention - educate pts to maintain hydrated and salt intake
IMMEDIATELY STOP LITHIUM
Hydration
Severe - forced diuresis or haemodialysis

Question 24

Serotonin Syndrome - commonest causes in clinical practice

Answer 24

• switching patients from one AD to another
• combining AD’s
• can also occur if AD + others meds/supplements e.g. St. Johns Wort or LSD, Cocaine etc

Question 25

Serotonin Syndrome Treatment

Answer 25

Stop meds
Symptomatic treatment + rehydration
Benzos for agitation
ED if severe Sx
OD - ?gastric lavage

Question 26

NMS vs SS
-associated treatment?
-onset?
progression?
Muscle rigidity?
Activity?

Answer 26

NMS

• APs
• Slow
• Slow
• Severe (lead pipe)
• Bradykinesia

SS

• Serotonergic meds
• rapid
• rapid
• less severe
• hyperkinesia