Emergencies

Question 1

What is the most common cause of suicide?

Answer 1

Hanging/strangulation

59% (m), 45% (f)

Question 2

What are RFs for suicide?

Answer 2

• Previous self-harm (70x increased risk if <1 year since DSH; 50% have DSH)
• Young male (Overall suicide risk = M: F = 3: 1)
• Occupation (doctor, vet)
• Live alone
• Mental illness (>90% have a mental illness (i.e. depression))
• Substance abuse
• Lower social class
• Unmarried (Divorced > single)
• Widowed/divorced (male > female)
• NSSI= Non-Suicidal Self Injury (i.e. EUPD)

Question 3

What are protective factors against suicide?

Answer 3

• Married (male = female)
• Lithium medication
• Faith in a religion
• No substance abuses

Question 4

What are some features of suicide?

Answer 4

• Incidence of suicide increases with age
• Bank holidays higher incidence
• Urban > rural suicide rates
• Higher risk = 1st week admission; within 1m of discharge

Question 5

What are indicators of higher suicide intent after DSH?

Answer 5

• Preplanning
• Actions in anticipation of death (a will, suicide note)
• Attempts at concealment
• Being alone at the time
• Stated wish to die
• Belief the act would be fatal (even if medically, it wouldn’t be)
• Lack of help-seeking following the act
• Sorrow/anger at failure
• On-going suicidal intent

Question 6

What is the reversing agent for BDZ OD?

Answer 6

Flumazenil

Question 7

What is the reversing agent for Z-drug (i.e. zopiclone) OD?

Answer 7

Flumazenil

Question 8

What is the reversing agent for opiate (codeine, methadone) OD?

Answer 8

Naloxone

Question 9

What is the reversing agent for paracetamol OD?

Answer 9

IV acetylcysteine

Question 10

What is neuroleptic malignant syndrome?

Answer 10

A life-threatening neurological emergency associated with the use of antipsychotic (neuroleptic) agents

Question 11

What is the aetiology of neuroleptic malignant syndrome?

Answer 11

• High dose typicals, most likely haloperidol
• Rapid dose changes
• RFs: male, younger age

Question 12

What are the S/S of neuroleptic malignant syndrome?

Answer 12

Gradual onset triad of…

• Mental status change (catatonia)
• Muscular rigidity
• Autonomic instability
  Hyperthermia (>40C)
  Tachycardia, tachypnoea
  Labile BP
  Sweating/fever

Question 13

What are the investigations for neuroleptic malignant syndrome?

Answer 13

• Serum CK (incl. high CK>1,000)
• Blood gas
• Blood glucose
• FBC (leucocytosis)
• U&Es (AKI > U&E derangement)
• LFTs (deranged)
• Rigidity > muscle breakdown > rhabdomyolysis (serious syndrome due to a direct or indirect muscle injury)

Question 14

What is the management of neuroleptic malignant syndrome?

Answer 14

• Immediate cessation of antipsychotic
• Transfer to hospital / ITU
• Supportive measures (rehydration, cooling, and treatment of rhabdomyolysis if present)
• Consider BZN (relax muscles / manage agitation)
• If severe NMS that has not responded to therapy, consider a dopamine agonist (bromocriptine or amantadine) or dantrolene

A delay of at least 2 weeks in restarting antipsychotic treatment is advised following full resolution of NMS.

Question 15

What are the S/S of serotonin syndrome?

Answer 15

Abrupt onset triad of…

• Mental status change (agitation, confusion, coma)
• Neuromuscular changes (jerking, twitching, hyperreflexia)
• D&V
• Autonomic instability
  Hyperthermia
  Tachycardia, tachypnoea
  Hypertension
  Sweating