Addictive Behaviours and Psychiatric Emergencies Flashcards by Amina Mohamed

What are some examples of psychiatric emergencies?

Neuroleptic Malignant syndrome
Serotonin syndrome
Acute dystonic syndrome
Alcohol withdrawal
Delirium tremens
Lithium toxicity
Self-harm - overdose, DSM, ligatures

DSM = deliberate self-harm

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What is neuroleptic malignant syndrome?

Adverse reaction to antipsychotics (dopamine receptor agonists) or abrupt cessation of dopaminergic meds (levodopa)

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Sx of neuroleptic malignant syndrome?

Hint - mnemonic FARM

Fever
Autonomic hyperactivity- tachycardic, htn
Rigidity (lead pipe) - severe
Mental state changes - confused, altered

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Ix and Tx of neuroleptic malignant syndrome?

Ix:
* Bloods - Inc. WBC + creatine kinase and dec. Fe
* CT/MRI head

Tx:
* Stop causative drug + supportive mx

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What is serotonin syndrome and what causes it?

Overactivation of serotonergic system (high synaptic conc of serotonin)

Caused by SSRIs, opioids, lithium, TCA (tricyclic antidepressants)

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Sx of serotonin syndrome?

Hint - mnemonic MAN

Mental state changes - confusion, hallucinations
Autonomic hyperactivity - hyperthermia (fever), htn, tachycardic, hyperreflexia
Neuromuscular abnormalities - clonus, tremor

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Tx of serotonin syndrome

Stop causative drug + supportive tx

If SSRI overdose - activated charcoal

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What is acute dystonic syndrome and what is it caused by?

Sustained, painful, involuntary contraction of muscle groups.

Usually caused by typical antipsychotics.

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Sx of acute dystonic syndrome?

Extremely painful contraction in the :
* Eye - oculogyric crisis
* Neck - antero/latero/retro torticollis
* Jaw
* Arm

Presnts as arm in dystnic posture, neck spasm to side, mouth open, upward eye gaze, pain and distress.

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Tx of acute dystonic syndrome?

Stop causative drug
IM procyclidine 5-10mg

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What is alcohol withdrawal and delirium tremens?

Alcohol withdrawal = sx that occurs when a person whose been drinking excessively suddenly stops
Delirium tremens = life threatening cdtn that develop around 72 hours after alcohol intake cessation and can persist for several days.

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What are the different tests used for alcohol abuse?

AUDIT
CAGE
FAST

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Sx of alcohol withdrawal and delirium tremens

Describe sx:
* 6-12 hrs after last drink
* 12-24 hrs post-drink
* 72 hrs post drink

Simple withdrawal (6-12 hrs after last drink):
* Insomnia
* Tremor
* Anxiety
* N+V
* Sweating
* Palpitations

Alcohol hallucinosis (12-24 hrs post):
* Visual, tactile or auditory hallucinations

Delirium tremens (72 hrs post):
* Delusions + hallucinations
* Confusion
* Seizures
* Autonomic hyperactivity - sweating, htn, tachycardic, hyperthermia

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Tx of:
* Alcohol withdrawal
* Delirium tremens

Alcohol withdrawal:
* Chlordiazepoxide (5-7 days)
* Pabrinex - to prevent Wernicke’s encephalopathy and replenish vitamins
* Fluids and anti-emetics
* Thiamine supplementation (3 mths)

Delirium tremens:
* Oral lorazepam - 1st line
* IV pabrinex

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What is Wernicke’s encephalopathy?

Syndrome associated with chronic alcohol abuse that occurs due to B1 (thiamine) deficiency - results in mammillary body atrophy. however, it’s reversible.

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Sx of Wernicke’s encephalopathy

Confusion
Ataxia
Ophthalmoplegia
Nystagmus
Less common - urinary incontinence, hypothermia

Tx = pabrinex and thiamine supps

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What is Korsakoff’s psychosis?

Irreversible manifestation of untreated Wernicke’s encephalopathy

Sx of Korsakoff’s psychosis

Retrograde amnesia (inability to remeber past events)
Anterograde amnesia (inability to form new memories)
Confabulation (generating false memories without intention of deceit)

Tx - pabrinex

What is lithium used for?

Used to primarily tx bipolar and mania but can also be used as a mood stabiliser.

Should be avoided in severe renal impairment.

What are the common side effects of lithium?

Fine tremor
Dry mouth
GI disturbance
Polydipsia and polyuria
Drowsiness

It’s a teratogenic medication

Sx of lithium toxicity

Coarse tremor
CNS disturbance - seizures, impaired co-ordination
Cardiac arrhythmias
Visual disturbance
Renal failure

Tx of lithium toxicity

Supportive mx - electrolyte balance, monitor renal function, IV fluid therapy
If severe - hameodialysis

To treat agitation and seizures - Benzodiazepines

What are the features of opiate intoxication?

Opiate = i.e. heroin

They act on opiate receptors

Drowsiness
Confusion
Dec. RR
Dec. HR
Constricted pupils
Track marks (needle marks) if the intravenous route has been used; abscesses at injection sites

What is opiate withdrawal? When does it occur?

Occurs as a result of opiate abuse. Can begin as early as 6 hours after last dose. However, symptoms peak at 36-72 hours.

Note - opiate withdrawal not as dangerous as alcohol withdrawal

Describe features of opiate withdrawal?

Agitation Anxiety and irritability Muscle aches or cramps Chills Runny eyes Runny nose Sweating Hypersalivation Insomnia

Tx of opiate withdrawal to help with sx?

* Methadone (detox programme) - may cause prolonged QTc * Lofexidine (relieve withdrawals) * Neltrexone (prevent relapse) - once detox is complete * Naloxone (overdose)

Cannabis intoxication sx? | Cannabis = marijuana ## Footnote They act on cannabinoid receptors

* Drowsiness * Impaired memory * Slow reflexes + motor skills * Increased appetite * Paranoia * Tachycardia * Dry mouth

LSD intoxication sx? | LSD = psychedelic drug ## Footnote They act on dopamine receptors

* Labile mood - emotional instability * Hallucinations * Inc. HR, BP and temp * Sweating * Insomnia * Dry mouth

What are some examples of static risk factors?

* Hx of self-harm/overdose * Previous hospitilisation * Hx of mental disorder * Hx of substance use disorder (overdose) * Personality disorder * Childhood adversity * Family history of suicide

What are some examples of dynamic risk factors?

* Suicide ideation and intent * Hopelessness * Psych symtpoms - hallucinations? * Treatment adherence * Substance use * Psychosocial stress

Tx for opiate overdose?

Naloxone

What is the most common agent for intentional self-harm in the UK?

Paracetamol (overdose)

Sx of paracetamol overdose?

Usually asx, but can have: N + V Loin pain Haematuria and proteinuria jaundice Abdo pain Coma ## Footnote Think of sx that happens as a result of liver/kidney damage

Build up of which toxic substance happens in paracetamol overdose?

NAPQI (N-acetyl-p-benzoquinone-imine)

Ix for paracetamol overdose?

Bloods: FBC, U&E, LFTs, Clotting screen, venous blood gas (severe metabolic acidosis), paracetamol levels

What are the main two tx for paracetamol overdose? Tx of paracetamol overdose: * If <1hr + dose >150mg/kg * If <4hrs * If 4-8hrs + dose >150mg/kg * If 8-24hrs + dose >150mg/kg * >24hrs * Staggered overdose

**Main two tx:** activated charcoal and N-acetylcysteine * * **If <1hr + dose >150mg/kg:** Activated charcoal * **If < 4hrs:** Wait until 4 hrs, take level and tx w/N-acetylcysteine based on level * **If 4-8hrs + dose >150mg/kg:** Start N-acetylcysteine immediately * **If 8-24hrs + dose >150mg/kg:** Start N-acetylcysteine immediately * **If >24hrs:** Start N-acetylcysteine immediately if pt has jaundice, RUQ tenderness, inc, ALT etc * **Staggered overdose:** Start N-acetylcysteine immediately

Sx of TCA overdose?

Drowsiness and confusion Cardiac arrhythmias Seizures Vomiting Dilated pupils

Ix for TCA overdose:

Bloods: FBC, U&E, CRP, LFTs, Venous blood gas (metabolic acidosis) ECG: Prolonged Qt interval (cardiac arrhythmia)

Tx of TCA overdose?

1. IV sodium bicarbonate 2. Activated charcoal within 2-4hrs of overdose

Tx of benzodiazapine overdose?

1. Activated charcoal 2. Flumanezil ## Footnote Flumazenil is a benzodiazepine receptor antagonist that competitively inhibits the activity of benzodiazepines