Emergency Psychiatry

Question 1

Predictors of violence?

Answer 1

Immediate past, recent past, and more distant history of violence is the best predictor of future violence

Question 2

What carries a 30x increased risk of violence than the general population?

Answer 2

Substance dependence or abuse

Question 3

What carries a 100x increased risk of violence than the general population?

Answer 3

Antisocial personality disorder with co-morbid substance abuse or dependence

Question 4

What carries a 9x increased risk of violence than the general population?

Answer 4

Mental illness (esp. paranoid schizophrenia and confused states related to medical problems)

Question 5

What med would you give to an agitated/violent patient?

Answer 5

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

Question 6

When would you NOT give a BZD to an agitated patient?

Answer 6

If possibility of being additive with other sedative hypnotic agents (e.g. alcohol) = excessive sedation and respiratory depression
Rare risk of allergic reaction

Question 7

What percent of population has paraxodical reaction and becomes more agitated with BZD?

Answer 7

5%

Question 8

What are the IM antipsychotics?

Answer 8

• 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

Question 9

What PO antipsychotics can be used in emergency setting?

Answer 9

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

Question 10

Which antipsychotic is most likely to cause EPS?

Answer 10

Haldol, then risperidone

Question 11

Demographic most likely to get EPS?

Answer 11

Young males and older women

Question 12

Typical EPS manifestations?

Answer 12

Muscle tightness in limbs, tongue thickness, neck tightness

Rarely laryngeal and pharyngeal spasm, sense of choking

Question 13

Treatment for EPS?

Answer 13

O2 if breathing problems
Diphenhydramine - IV form acts quickly, IM takes 30 min, PO takes 60 min
Benztropine - IM or PO

Question 14

What percent of patients with serotonin syndrome present within 6 hours after initial use, overdose, or change in dosing?

Answer 14

60%

Question 15

What percent of overdoses are with SSRIs?

Answer 15

14-16%

Question 16

What drug interactions are associated with severe serotonin syndrome?

Answer 16

Phenelzine and meperidine
Tranylcypromine and imipramine
Phenelzine and SSRI
Paroxetine and buspirone
Linezolid and citalopram
Tramadol, venlafaxine, and mirtazapine

Question 17

Serotonin syndrome triad?

Answer 17

• 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

Question 18

Treatment of serotonin syndrome?

Answer 18

Discontinue all sertotonergic agents, supportive
Cyproheptadine (serotonin antagonist)
Intubation and ventilation if severe with hyperthermia (temp >41.1 C)

Question 19

Demographic/environmental risk factors for suicide?

Answer 19

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)

Question 20

Clinical risk factors for suicide?

Answer 20

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

Question 21

Protective factors for suicide?

Answer 21

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