Alcohol/Psych in the ED Flashcards
What might your interaction be like if the patient has borderline personality disorder?
what are some characteristics of this PD?
enjoyable to talk to while in the room, but you feel exhausted when walk out of room (like pt “sucks the life out of you”)
if pt feels you went against them, they will turn on you
- Mood instability
- Aggression
- Tendency to intense anger
- Impulsivity
- Frequent self injury
delerium
vs
psychosis
vs
dementia
►delerium (medical/toxins)→ reversible
hypoglycemia, menigitis, stroke, hypoxia, Na, alcohol
vs
►psychosis (impaired contact with reality-psych)
vs
►dementia (slow onset/ memory & coginition impairment)
parkinsons, alzheimers, repetitive trauma (soccer player)
What is porphyria?
(and why is on your differential for intoxication)
Porphyrias are inherited defects in the biosynthesis of heme.
Possible S/ Sx of acute porphyria include:
- Severe abdominal pain/ distension
- Pain in your chest, legs or back
- Constipation or diarrhea, Vomiting
- Insomnia
- Heart palpitations, High blood pressure
- Anxiety or restlessness
- Seizures
- Confusion, hallucinations, disorientation or paranoia
- Breathing problems
- Muscle pain, tingling, numbness, weakness or paralysis
- Red or brown urine
Acute psychois + physical finding (good patterns to remember):
Fever/Alcoholism/Headache/abdominal pain/sweating/automonic signs + psychosis ⇒
- Fever and psychosis : Meningitis
- Alcoholism and psychosis : Wernicke’s
- Headache and psychosis : Tumor/ICH
- Abdominal Pain and psychosis : Porphyria
- Sweating and psychosis : Hypoglycemia, DTs
- Autonomic signs (Dizziness, sweating, palpitations) and psychosis : Toxic or metabolic encephalopathy
Life threatening medical conditions that can masquerade as psychosis?
- hypoxia
- CNS infection
- CNS trauma
- Intoxication
- Etoh/drug withdrawal
- Hypoglycemia
- Hypoxia
- ICH
- Poisoning: acetominophen/salicylates/TCAD/etc
- Seizure disorder Acute organ system failure
How do you evaluate a pt that has been sent to you for medical clearance (r/o organic causes)?
vitals okay
can’t be intoxicated (functionally)
can’t be suicidal/ homicidal
ABCDEs
full neuro exam (including vision)
oriented to person, place, time→full MMSE if abnormal answers
► REASSESS before discharge
Functional vs organic (psych vs medical…)?
Medical: visual halluncinations common
- without psych Hx
- Age <12 years >40 Years old
- Sudden onset and fluctuating course
- Disoriented
- Emotional liability
- Abnormal Physical exam
- History of substance abuse or toxins
Psych: auditory hallucinations MC
- 13-40yo, with psychiatric history
- Gradual onset and continuous course
- Scattered thoughts
- Awake and alert
- Flat affect
- Normal Physical exam
Markers for medical disease as the cause of behavioral complaints:
♦40+yo without prior history of psychiatric illness
If had bipolar, schizophrenia should have had at younger age
♦Abnormal vital signs
♦Recent memory loss
♦Altered mental status
How long is psych hold?
72 hours
One of three criteria must be met
►Gravely disabled
(eg so drunk doesn’t know what is going on)
►Imminently dangerous to self
►Imminently dangerous to others¨
**Security guard will sit outside room until seen by psych
If considering delerium, psychosis, which lab values should you always get?
always get a glucose and oxygen level, a urine alochol/ toxicolgy test
Besides a calm, non-imposing manner, enlisting a security guard and potentially using restraints, what might you use to keep an agitated pt calm? (pharmacologic)
Ativan 1-2mg for: Agitation, mania, withdrawal, sympathomimetics
Traditional antipsychotic: Haldol 5-10mg
Atypical Antipsychotics: Zyprexa 5-10mg po/IM
B52: benedryl, 5mg Haladol, 2mg Ativan
►B52 (will knock pt out for ~8hrs, so be prepared to have them stay)
to Dx panic disorder, must exclude:
MI
hypoxia
ischemia (stroke)
seizures
grand mal seizure= generalized (tonic→clonic→postictal)
petite mal= abscence seizure
focal= partial seizure
generalized=
tonic: loss of consiousness, fall, respiratory arrest ~1min
clonic phase: jerking, +/- tongue biting, incontinence 1-3min
postictal:sleepy, headache, N/V, myalgias 15-60min
focal= risk of tumor
1st time seizure w/u:
Tx?
- fever
- CT (bleed)
- EKG
- pregnancy (for Tx options)
- Ca, Mg, Na, K, glucose, CBC, tox screen
- lumbar puncture with SAH, fever or immunocompromised
- loss of consciousness, bowel/bladder control
Can go home wihtout any meds if stablized, but need neuro f/u with EEG. No driving.
If known history of seizure, what 2 labs need?
check blood levels of anti-seizure meds and glucose
If seizing for 5+min continuously or if more than 1 seizure without recovery inbetween (status epilepticus), what things must you do?
MUST stop seizure bc pt is anoxic!
ABC’s, IV, O2, monitor, labs, urine tox, temp
1st line: lorazapam→diazapam (benzos)
2nd: phentoin (Dilantin)
refractory: use barbituates or propafol, midazolam
Pearls: if not sure if psycogenic or real seizure, can measure prolactin
60 min post-seizure:
►prolactin up and anion gap with low bicarb if real seizure
Criteria for febrile complex seizure:
complex seizure lasts >15 min, multiple seizures, postictal period, focality, outside of 6m-5yr age group
what type of eval needed for alcohol intoxication?
can’t go home until fxnally not intoxicated
can’t drive if legally drunk (D/C to sober adult or rehab)
if minor: must discharge to parent/guardian
Worry about Wernickes encephalopathy (thiamine deficiency) in alcoholics–> nystagmus, ataxia, confusion (must give THIAMINE before GLUCOSE with banana bag in severe intoxication)
screen for electrolyte abnormality, esp Mg
Findings with alcoholic ketoacidosis
(usually binge drinking followed by days of starvation)
Kussmal’s respiration (occasional SOB)
N/V/abdominal pain with gastritis, pancreatitis worsen condition (check lipase labs)
Mixed acid/base disturbance: (low pH, low bicarb)
- ketoacidosis (metabolic acidosis)→ low glucose
- Withdrawal related hyperventilation (respiratory alkalosis)
- Protracted emesis (metabolic alkalosis)
EtOH undetectable bc can’t keep anything down, ketones may not be evident on dipstick due to type of ketones
**Usually corrects in 12-16 hours
type of withdrawals (level of) with alcohol:
**alcohol binds to GABA receptor (inhibitor)→ why withdrawal gives seizure
minor: withdrawal tremulousness (6-24 hours after drinking, lasts less than 48 hours), anxious
major: 10-72 hours after drinking; up to 5 days, whole body tremor, HTN, sweating, fever, vomiting, hallucinations (visual, auditory)
Withdrawal Seizures: Occur within 6-48hrs after last drink, Generalized, brief ►30-40% go on to DTs
Delirium Tremens: (global confusion, SNS overdrive→CV collapse, incontinence, tremor, fever, hallucinatins,)
LIFE THREATENING ►15% mortality.
Onset usually > 3 days since last drink
►Profound global confusion is hallmark of dx
signs of isopropol alcohol use
(eg Rubbing alcohol, skin and hair products, paint thinner, antifreeze)
Smells of rubbing alcohol of fruity odor of ketones
Large osmolality gap (Measured Serum Osm – Calculated Serum Osm), plus:
- No significant acidosis
- Negative ethanol level
- →Supportive treatment
Heavy use of what drug is linked to stroke in younger people?
heavy pot smokers
If someone has been put on a “mental health hold”, what must he/she have before can be discharged?
Psychiatric evaluation (by psychiatry)
