Addictive Behaviours and Psychiatric Emergencies Flashcards
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
What is neuroleptic malignant syndrome?
Adverse reaction to antipsychotics (dopamine receptor agonists) or abrupt cessation of dopaminergic meds (levodopa)
Sx of neuroleptic malignant syndrome?
Hint - mnemonic FARM
- Fever
- Autonomic hyperactivity- tachycardic, htn
- Rigidity (lead pipe) - severe
- Mental state changes - confused, altered
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
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)
Sx of serotonin syndrome?
Hint - mnemonic MAN
- Mental state changes - confusion, hallucinations
- Autonomic hyperactivity - hyperthermia (fever), htn, tachycardic, hyperreflexia
- Neuromuscular abnormalities - clonus, tremor
Tx of serotonin syndrome
Stop causative drug + supportive tx
If SSRI overdose - activated charcoal
What is acute dystonic syndrome and what is it caused by?
Sustained, painful, involuntary contraction of muscle groups.
Usually caused by typical antipsychotics.
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.
Tx of acute dystonic syndrome?
Stop causative drug
IM procyclidine 5-10mg
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.
What are the different tests used for alcohol abuse?
AUDIT
CAGE
FAST
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
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
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.
Sx of Wernicke’s encephalopathy
Confusion
Ataxia
Ophthalmoplegia
Nystagmus
Less common - urinary incontinence, hypothermia
Tx = pabrinex and thiamine supps
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
They act on cannabinoid receptors
- Drowsiness
- Impaired memory
- Slow reflexes + motor skills
- Increased appetite
- Paranoia
- Tachycardia
- Dry mouth
LSD intoxication sx?
LSD = psychedelic drug
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
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 <1hr + dose >150mg/kg:
-
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?
- IV sodium bicarbonate
- Activated charcoal within 2-4hrs of overdose
Tx of benzodiazapine overdose?
- Activated charcoal
- Flumanezil
Flumazenil is a benzodiazepine receptor antagonist that competitively inhibits the activity of benzodiazepines
