Emergency Psychiatry Flashcards
Predictors of violence?
Immediate past, recent past, and more distant history of violence is the best predictor of future violence
What carries a 30x increased risk of violence than the general population?
Substance dependence or abuse
What carries a 100x increased risk of violence than the general population?
Antisocial personality disorder with co-morbid substance abuse or dependence
What carries a 9x increased risk of violence than the general population?
Mental illness (esp. paranoid schizophrenia and confused states related to medical problems)
What med would you give to an agitated/violent patient?
Lorazepam (in first 24 hrs addresses agitation as effectively as antipsychotics even if psychosis is present)
1-2 mg IM, IV, or PO Q1-2 hrs
When would you NOT give a BZD to an agitated patient?
If possibility of being additive with other sedative hypnotic agents (e.g. alcohol) = excessive sedation and respiratory depression
Rare risk of allergic reaction
What percent of population has paraxodical reaction and becomes more agitated with BZD?
5%
What are the IM antipsychotics?
- Ziprasidone - NTE 40 mg/24 hrs
- Olanzapine - NTE 20 mg/24 hrs (caution with elderly)
- Haloperidol - NTE 20-30 mg/24 hrs
- Droperidol - back box warning for arrhythmias
What PO antipsychotics can be used in emergency setting?
Risperidone - NTE 6 mg/24 hrs, comes in rapid melting tab
Olanzapine - NTE 20 mg/24 hrs, comes in rapid melting tab
Haloperidol - NTE 30 mg/24 hrs
Which antipsychotic is most likely to cause EPS?
Haldol, then risperidone
Demographic most likely to get EPS?
Young males and older women
Typical EPS manifestations?
Muscle tightness in limbs, tongue thickness, neck tightness
Rarely laryngeal and pharyngeal spasm, sense of choking
Treatment for EPS?
O2 if breathing problems
Diphenhydramine - IV form acts quickly, IM takes 30 min, PO takes 60 min
Benztropine - IM or PO
What percent of patients with serotonin syndrome present within 6 hours after initial use, overdose, or change in dosing?
60%
What percent of overdoses are with SSRIs?
14-16%
What drug interactions are associated with severe serotonin syndrome?
Phenelzine and meperidine Tranylcypromine and imipramine Phenelzine and SSRI Paroxetine and buspirone Linezolid and citalopram Tramadol, venlafaxine, and mirtazapine
Serotonin syndrome triad?
- Mental status changes (confusion, restlessness, AGITATION, anxiety, decreased consciousness)
- Neuromuscular abnormalities (TREMOR, rigidity, CLONUS, myoclonus, HYPERREFLEXIA, ataxia)
- Autonomic hyperactivity (DIAPHORESIS, hyperthermia, shivering, mydriasis, nausea, diarrhea)
VS: tachycardia, labile BP changes
Treatment of serotonin syndrome?
Discontinue all sertotonergic agents, supportive
Cyproheptadine (serotonin antagonist)
Intubation and ventilation if severe with hyperthermia (temp >41.1 C)
Demographic/environmental risk factors for suicide?
Caucasian or Native American Male >65 y/o Unmarried, living alone Unemployed Family hx of suicide in 1st degree relative Recent interpersonal loss Lethal means available (esp. firearms)
Clinical risk factors for suicide?
Personal history of suicide attempt Substance use Chronic medical illness Agitation Psychiatric (schizophrenia, depression, bipolar, borderline or antisocial PD) H/o traumatic brain injury Current hopelessness, anhedonia or apathy, sleep disturbance, social isolation Recent psych hospitalization
Protective factors for suicide?
Actively making plans for future Verbalize hope for the future Cognitive flexibility Responsibility to dependents Therapeutic relationship with treatment provider Social network or family Belief that suicide is immoral or will be punished Fear of social disapproval of suicide Fear of the act of suicide
