CASC Stations Flashcards
Management of DT
Ensure adequate fluid and e- balance and nutrition
Optimal environment, well lit
Consistent nursing support for reassurance and reorientation
Librium sliding scale
Parental B12
Risk of seizures and Wernickes
Risk of death in DT if untreated
10%
When does DT peak
72-96 hours after last drink
Classic sx of DT
Clouding of consciousness Confusion Hallucinations in every modality Tremors Fleeting paranoid delusions Sleep disturbance Autonomic hyperactivity - fever, tachy, sweating, HTN
What does Pabrinex contain
Pabrinex also contains nicotinamide, pyridoxine (vitamin B6), riboflavin
(vitamin B2) and vitamin C.
Mortality rate of untreated Wernickes
20%
Which antidepressants to avoid post-MI
Citalopram and Fluvaxamine
TCA - can cause hypotension
Augmentation options in treatment resistant depression
Augmentation of
antidepressants with: Lithium
Tri-iodothyronine, High dose venlafaxine
L-Tryptophan
Combination of SSRI with mirtazapine.
ECT
Augmentation of clozapine options
- Add Risperidone
- Add Sulpiride
- Add Amisulpiride
- Add Haloperidol
- Add Lamotrigine
- Add Omega-3-triglycerides
Core sx of depression
- Pervasive low mood
- Anhedonia
- Reduced energy and fatigueability
‘Other’/criterion B sx of depression
- Biological symptoms such as disturbance in sleep, poor appetite and
reduced libido - Cognitive symptoms like impaired memory, reduced attention and
poor concentration - Behavioural symptoms such as reduced eye contact, social withdrawal
and psychomotor retardation - Emotional symptoms such as low confidence and low self-esteem
- Depressive cognitions such as feeling of helplessness, hopelessness,
worthlessness and feelings of guilt.
How many patients with severe depression have hallucinations?
10-20%
Efficacy of combination meds for psychotic depression
70-80% patients improve
How much more likely are patients with SCZ to develop DM?
2x more than gen pop
How much more likely is metabolic syndrome in those with psychosis on antipsychotics?
2-4x more (typical and atypical antipsychotics)
Symptoms of NMS
Fever, diaphoresis, rigidity, confusion, fluctuating consciousness,
fluctuating blood pressure, tachycardia
What is NMS?
A rare, life-threatening, idiosyncratic reaction to antipsychotic medication
Course of NMS
May last 7-10 days after stopping oral antipsychotics and up to 21 days
after depot antipsychotics (e.g. fluphenazine).
Risk factors of developing NMS
- High potency typical antipsychotic drugs
- Recent or rapid dose increase of antipsychotics
- Rapid dose reduction
- Abrupt withdrawal of anticholinergic drugs
- Psychosis, organic brain disease, alcoholism, Parkinson’s disease
- Hyperthyroidism
- Agitation
- Dehydration.
Physical consequences of NMS
Rhabdomyolysis, renal failure, aspiration pneumonia, seizures,
respiratory failure, arrhythmias, DIC, worsening of primary psychiatric disorder
(due to withdrawal of antipsychotics).
Management of NMS in medical unit
• Rehydration.
• Supportive measures-Oxygen, correct volume depletion and hypotension with
IV fluids, reduce the temperature using cooling blankets, antipyretics
• Sedation with benzodiazepines which are useful in reversing catatonia, are
easy to administer, and can be tried initially in most cases.
• 1st line pharmacotherapy to reduce rigidity: Dantrolene sodium appears
to be beneficial in cases of NMS involving significant rigidity and
hyperthermia. It has been beneficial in rapidly reducing extreme temperature
elevations in many cases.
• 2nd line pharmacotherapy to reduce rigidity: Trials of bromocriptine,
amantadine, or other dopamine agonists may be tried in patients with
moderate symptoms of NMS. L-dopa and carbamazepine have also been
used.
• 3rd line-ECT, Consider ECT for treatment after other interventions have
failed.
• Rhabdomyolysis: vigorous hydration and alkalisation of the urine suing IV
sodium bicarbonate to prevent renal failure.
• Artificial ventilation if required.
Antipsychotic rechallenge post-NMS
• Stop antipsychotics for at least 5-7 days, preferably longer.
• Allow time for symptoms and signs to resolve completely.
• Begin with very small dose and increase very slowly with close monitoring of
temperature, pulse and blood pressure.
• CK monitoring may be useful.
• Consider using an antipsychotic structurally unrelated to that associated with
NMS or a drug with low dopamine affinity (quetiapine or clozapine).
• Avoid depots and high potency conventional antipsychotics for the future.
Mortality rate of NMS
5-20%
Good prognosis with supportive care
Sx of NMS vs Seretonin syndrome
Onset days-weeks (NMS) vs minutes to hours (SS)
Resolves in 2 weeks (NMS) vs resolves in 24 hours (SS)
No myclonus (NMS) vs myoclonus (SS)
Hypomania not present (NMS) vs hypomania may be present (SS)
Reflexes normal or absent (NMS) vs hyperreflexia (SS)
Rhabdomyolysis + acidosis (NMS) vs muscle breakdown not common (SS)
Elevated CK and WCC (NMS) vs less frequent lab abnormalities (SS)
How much Lithium is excreted in breast milk
40-50% of maternal serum level
Relapse rate postpartum of bipolar if lithium stopped
Up to 70%
Monitoring in last trimester if using lithium
Measure serum levels weekly and use smaller divided doses in last month
Discontinue lithium 2-3 days before delivery or decrease dose by half or quarter - helps against potential toxicity to mother as she may get dehydrated during labour and safeguards neonatal withdrawal
Recommended antidepressants in pregnant women
Nortriptyline
Amitriptyline
Imipramine
Fluoxetine
Relapse rate in pregnant women with history of depression
68% if discontinue antidepressant vs 26% who continue treatment
Risk of spontaneous abortion on SSRI
13.3%
Risks with SSRI in pregnancy to fetus
Spontaneous abortion 13.3%
Decreased gestational age
Low birth weight
Risk of persistent pulmonary HTN in late pregnancy
What to monitor on methylphenidate
BP, Pulse, height & weight, monitor for
insomnia, mood and appetite changes and the development of tics
regularly
• Monitor response using Connor’s rating scale
• Discontinue if no benefits seen in 1 month
What age of children is methylphenidate not licensed in?
<6
How many children with ADHD will continue to have clinically significant symptoms into childhood?
66%
Sx of hyperactivity in ADHD
ü Fidgets with hands or feet- The symptom of ‘nervousness’ is often
reported
ü Has trouble sitting still- Individuals may describe feelings of discomfort
that are relieved only with physical activity. There may be physical or
verbal overactivity
ü Feels restless and jittery- Individuals may find it very difficult to rest,
moving about excessively, squirming or fidgeting
ü Often talk excessively
ü Has trouble doing things quietly, either interrupting others
ü Is a person who is ‘on the go’
Sx of impulsivity
ü Gets frustrated when having to wait for things
ü Interrupts other people’s conversations and not letting others express
their views which often undermines the quality of social interactions
ü Acts before thinking things through- Problems may arise as a result of
aggressive driving, impulsive and injudicious spending, or starting
multiple projects without carrying them through to completion.
Sx of inattention in ADHD
ü Does not pay close attention to what he or she is doing and makes
careless mistakes
ü Has trouble paying attention to tasks
ü Has trouble following verbal instructions
ü Starts things but does not finish them
ü Has trouble getting organized
ü Tries to avoid doing things that require a lot of concentration-watching
TV or reading
ü Misplaces things
ü Is easily distracted by other things going on
ü Is forgetful
Response to ADHD meds in adults with ADHD
66%
Firstline treatment for ADHD
Methylphenidate, Dexamfetamine and Atomoxetine
Second list treatment for ADHD
Imipramine, clonidine
What to monitor if using Methylphenidate
Weight loss, growth retardation, HR and BP, tics
What to monitor if using Dexamphetamine
Weight loss and growth retardation, HR and BP, tics
How many women suffer from postnatal depression
1 in 10
When does PND often occur
Within one mont of delivery but can start up to 6 months later.
Risk factors of PND
Previous history of depression (especially PND), Lack
of support from the partner and family, Recent stressful life events, An
accumulation of misfortunes such as bereavement, the partner losing his
job, housing and money problems,
Risk of relapse in PND
The chance of someone without a history of depression getting a PND is
10–15% and someone who already had one episode of PND getting a
second one is higher which is around 20–40%.
Risk factors for PND
- Older Age
- Single mother
- Unplanned pregnancy
- Personal history of depression
- Family history of depression
- Poor social support
- Significant other psychosocial stressors
Prognosis of PND
a) The recurrence rate of depressive illness in the puerperium after subsequent
childbirth would be 20 – 30%.
b) 50% women who have suffered a puerperal depressive illness will later suffer
a depressive illness that is not puerperal.
Risk factors for postpartum psychosis
- Personal history of major psychiatric disorder
- Previous postpartum psychosis (30% risk of developing psychosis in the
subsequent pregnancies) - Family history of major psychiatric disorder
- Single parenthood
- Lack of adequate social support
Incidence of postpartum psychosis
1.5/1000 live births
Peak occurrence of postpartum psychosis
2 weeks postpartum
Good prognostic factors of postpartum psychosis
- Acute onset
- Affective illness
- Good social support.
- First episode
- Well adjusted pre morbid functioning
- Lack of social adversities.
Risk of postpartum psychosis
ü General population-0.1-0.25%
ü The risk of perinatal psychosis is about 50% in women with a history of
bipolar disorder
ü The risk of postpartum psychosis in patient with a history of postpartum
psychosis is 50-90%
Antipsychotics to use during breastfeeding
Sulpride
Olanzapine
Antidepressants to use during breast-feeding
Paroxetine
Sertraline
What is panic disorder?
• Symptoms must be present for at least one-month duration to diagnose
panic disorder.
• In ICD-10 Panic disorder is graded as severe if there are more than 4 attacks
per week in a 4-week period.
Aetiology of panic attacks
v There is an increased family history of agoraphobia, depression and suicide
v An association has also been found between panic disorder and childhood
parental separation from the mother/parental death
v Pre-morbid overanxious personalities or otherwise high levels of anxiety
predispose an individual to panic disorder
v Panic attacks may also be provoked by excessive caffeine intake,
sympathomimetic drugs, injections of sodium lactate, inhalation of
carbondioxide
v Other theories include increased post synaptic response to serotonin,
increased adrenergic activity and decreased inhibitory reactive sensitivity due
to GABA.
v Panic attacks are mediated by a ‘fear network’ in the brain that involves the
amygdala, the hypothalamus, and the brainstem centres
v Hyperventilation: Hyperventilation is also considered a possible cause of
panic disorders. There is evidence that voluntary over breathing can produce
a panic attack
Aetiology of agoraphobia
Ø There is limited evidence of a genetic inherited predisposition to develop
agoraphobia
Ø The development of phobias can arise spontaneously
Ø It is frequently precipitated by traumatic events such as bereavement,
illness or divorce
Ø Individuals are more likely to have a dependent, immature and possibly
introverted pre-morbid personality
Ø Perpetuating factors may include drug and alcohol misuse, also the
collusion of family members (secondary gain from a spouse)
Ø Phobic disorder such as agoraphobia can get worse with intercurrent
depressive episodes.
