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)
Good Hx questions to ask with psych pt:
►Must be patient, never laugh, never scoff
Gather history from friends and family, EMS
- Always ask why now? Why today?
- What has happened to their coping skills?
- What is acute and what is chronic about the crisis?
Questions MUST ask every patient coming into ED with altered mental status:
Do you want to kill yourself or anyone else?
Seeing or hearing things?
Have you taken any drugs or alcohol?
→Do you have any mental Dx? Have you missed any meds?
What are some medications with behavioral modifications?
Steroids- hyped up
TCAs
Anticonvulsants
Benzos- sleepy
Amphetamines/related drugs
Narcotics
Antidysrhythmics
Street drugs – alcohol, cocaine, meth
Tests vary hospital to hospital, but which toxins can be screen for (and from which sample type)?
Standard Blood:
- EtOH, Acetaminophen, Salicylates, TCAD
Urine: (drugs of abuse) -
- amphetamines
- benzodiazepines
- marijuana
- barbiturates
- cocaine
- narcotics
- MDMA (ecstasy)
**No designer drugs on standard tox screens
What are the criteria for major depressive disorder?
Occuring daily for more than 2 weeks:
Depressed Mood OR Anhedonia
PLUS
5+ of SIG E CAPS
What does SIG E CAPS stand for?
S sleep
I Interest
G Guilt
E Energy
C concentration
A appetite
P psychomotor changes
S suicidal feelings
Criteria for bipolar manic episode:
> 1 week of: abnormally elevated or irritable mood with 3+ of:
- inflated self-esteem
- distractability
- decreased need for sleep
- pressured speech
- flight of ideas
- psychomotor agitation
- Increased risk taking
Criteria for a panic attack:
An episode of intense fear or discomfort in which 4 of the following Sx develop abruptly and peak with in 10 minutes
- SOB
- Dizziness
- Palpitations
- Trembling
- Sweating
- Choking
- Nausea or abdominal distress
- Chest Pain
- Hot flashes
- Paresthesias
- Fear of going crazy
- Fear of dying
What demographic is most at risk for suicide?
MC: elderly, white, male
85+yo WM, 6x national average suicide rate
How can we classify lethality in someone who is suicidal?
-
Passive suicidal ideation
- absence of a specific plan
-
Active suicidal ideation
- specific plan regardless of viability of the plan
-
Suicide attempt
- act of self harm with intent to die
- Taking a lot of Tylenol or cutting in line with arteries/veins is very high intention/risk
-
Suicidal gesture
- Self inflicted harm without the expectation of death
-
At risk for serious injury or accidental death
- Typically impulsive and poorly tolerant of frustration
When does a patient need to be put on 1:1 security watch?
- Unable to commit to safety
- Patient is agitated or impulsive
- Patient is delirious, disoriented, or cognitively impaired
- Provider is intuitively uncomfortable with the patient leaving the department
- Err on the side of safety- PA CAN override psych
- Provide a safe environment
Thoughts on “suicide contracts” in ED?
Suicide contracts in the ED offer no legal protection
questionable efficacy
DDx for a seizure:
Syncope
Hyperventilation syndrome
Psychogenic seizures
Atypical migraine
Movement disorders
Todds Paralysis: focal paresis after seizure can indicate what as the cause of the seizure?
a focal cerebral lesion
Tx for a simple febrile seizure?
¨Generalized
¨lasts <15 minutes
¨Temp > 38C / 100.4 F
¨Classically 6mo -5 year of age
Identify and treat any fever sources
(AOM, PNA, UTI)
Antipyretics: rectal Tylenol 15mg/kg, Advil 10 mg/kg
Lorazepam .05-0.1mg/kg
How long will it take alcohol to be eliminated from body?
Metabolized by the liver, by alcohol dehydrogenase
►Steady state of elimination 15-40 mg/hour
If at 300 and need to get to 100, increments of 40mg/hr, will take at least 5 hours…
Why should most women drink less alcohol than male counterparts?
Women have less alcohol dehydrogenase, so slower metabolism
Women have less gastric metabolism than men
What ramifications of thiamine deficiency are associated with alcoholism?
Wernicke’s Classic TriadKorsakoff Syndrome
→Nystagmus →persistent learning &
→Ataxia memory deficits
→Confusion
These are not 2 separate entities, but rather a spectrum of illness
Give thiamine if giving glucose with IV to prevent this.
What are general symptoms of alcohol withdrawal?
PE: Hyperadrenergic state
►Life threatening!
(HTN, tachycardia, diaphoresis, agitation, tremor, mild fever, hallucinations (visual) and possibly seizures)
Tx of alcohol withdrawal:
- Evaluate for co-morbidities (head CT, LP and CXR)
- Correct fluid and electrolyte imbalances
- Meds: usually benzos. May require large doses.
- ¨Ativan 1-4mg IV q hour to effect. (Start with 2mg)
- ¨Tranxene 15-30 mg PO Q 6-8 hours for discharge
- Will be asked by detox to send pt to them with a “6pack of Tranxene”
- ¨May require Beta-blockers or Clonidine to blunt adrenergic effects
- ¨Haldol to help with hallucinations, prn
Signs of methanol consumption
Metabolizes to Formaldehyde
- Increased Osm Gap
- Accumulates in the retina→ edema; visual “snowstorm”
- GI irritant
- CNS changes
Signs of Ethylene Glycol ingestion:
Presents classically with Flank Pain, ATN, ARF
→Urinary Oxalate Crystals
Similarities between Methanol/ Ethylene Glycol:
Increased Anion Gap
Symptoms and acidosis often delayed
(if not diagnosed early, irreversible damage)
Tx: fomepizole, ethanol, dialysis
