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Psych Week 3 > ICL 8.9: Psychopharmacology of Agitation & Behavioral Emergencies > Flashcards

ICL 8.9: Psychopharmacology of Agitation & Behavioral Emergencies Flashcards

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1
Q

what is considered a psychiatric emergency?

A
  1. risk of violence to self
  2. risk of violence to others
  3. new onset psychosis
  4. catatonia
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2
Q

what is considered a medical emergency?

A
  1. intoxication
  2. overdose
  3. agitation
  4. serotonin syndrome
  5. neuroleptic malignant syndrome (NMS)
  6. delirium
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3
Q

what is agitation?

A

an extreme form of arousal that is associated with increased verbal and motor activity

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4
Q

wig gets agitated?

A
  1. those with and without mental illnesses
  2. those with and without substance use disorders
  3. those on and off psychotropic medications
  4. those with and without medical comorbidities
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5
Q

what is the most important part of the assessment of agitation from most to least important?

A
  1. medical illnesses**
  2. medication/substance use related**
  3. psychotic disorders
  4. mood disorders
  5. anxiety disorders
  6. personality disorders
  7. other psychiatric illnesses
  8. situational problems
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6
Q

what should you ask about during an HPI for someone with agitation?

A
  1. baseline behaviors
  2. baseline mental status
  3. medication adherence
  4. past and current substance use
  5. past and current physical health
  6. recent changes: illness, fever, trauma, medication, changes, drug use, symptoms with a focus on neurological and psychiatric symptoms
  7. verify prescriptions

the HPI has a sensitivity of 94% in detecting medical illness in psychiatric patients

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7
Q

what is the progression of the symptoms of alcohol withdrawal?

A

MINOR SYMPTOMS

  1. anxiety
  2. insomnia
  3. GI upset
  4. headache
  5. palpitations
  6. anorexia

there can also be alcoholic hallucinosis, withdrawal seizures, or delirium tremens

minor symptoms –> alcoholic halllucinosis(1 day) –> withdrawal seizures (2 days)–> delirium tremens (3 days)

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8
Q

what is delirium tremens?

A

a condition caused by severe alcohol withdrawal

  1. agitation
  2. hallucinations
  3. disorientation
  4. tachycardia
  5. HTP
  6. fever
  7. diaphoresis
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9
Q

what is serotonin syndrome?

A
  1. akathisia
  2. tremors
  3. altered mental status
  4. clonus
  5. muscular hypertonicity
  6. hyperthermia

any SSRI or SNRI increases your risk for serotonin syndrome; also antipsychotics can cause this

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10
Q

what is a serious side effect of lithium?

A

renal failure

parathyroid dysfunction

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11
Q

what are some of the side effects of clozapine?

A
  1. confusion
  2. muscarinic side effects
  3. hypotension
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12
Q

what happens if you stop venlafaxine?

A

it’s an SNRI antidepressant that has THE shortest half life!

so if you stop it you’re going to have horrible withdrawal symptoms and you’re going to feel agitated, anxious, panic attacks, emotional lability

you can get all this from missing just one more dose!

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13
Q

what is the clinic presentation of someone with PCP intoxication?**

A
  1. aggression
  2. vertical nystagmus
  3. elevated BP
  4. hallucinations
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14
Q

what is the clinic presentation of someone with cocaine intoxication?**

A
  1. euphoria
  2. paranoia
  3. cardiac side effects
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15
Q

what is the clinic presentation of someone with hallucinogens intoxication?**

A
  1. pupillary dilation

2. perceptual distortions

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16
Q

what is the clinic presentation of someone with methanol intoxication?**

A
  1. visual disturbances
  2. ataxia
  3. confusion
17
Q

how do you treat BZD, opioid, TCA, B blocker, and anticholinergic substance overdose?

A
  1. benzodiazepine –> flumazenil is the antidote
  2. opioids –> naloxone
  3. TCA –> sodiumbicarbonate
  4. B blocker –> glucagon
  5. anticholinergics –> atropine
18
Q

what are the side effects of paroxetine?

A

paroxetine is THE most anticholinergic of the antidepressants

the threshold for having anticholinergic toxicity symptoms decreases as you get older

venlafaxine is the shortest 1/2 life

19
Q

what are anticholinergic drug toxicities?

A

blind as a bat = dry eyes, difficulty adjusting visual focus/lens accommodation, sensitivity to bright light due to dilated pupils

mad as a hatter = hallucinations, tremulousness, memory impairment

red as a beet = flushing

hot as a hare = decreased sweating

dry as a bone = dry mouth, difficulty swallowing

the bowel and bladder lose their tone = constipation, urinary retention

the heart runs alone = tachycardia

20
Q

which drugs can cause anticholinergic toxicity?

A
  1. muscarinic antagonists = atropine, scopolamine, hyoscine, benztropine, many plants
  2. muscarinic antagonists with other mixed effects = antihistamines, TCAs, antipsychotics
  3. decrease ACh release = carbamazepine, opiates, cannabinoids, ethanol, clonidine
  4. decreased ACh synthesis = thiamine deficiency
21
Q

what is the antidote and MOA of the antidote for anticholinergic medication overdose?**

A

physostigmine

acetylcholinesterase inhibitor

22
Q

what is the antidote and MOA of the antidote for benzodiazepine overdose?**

A

flumazenil

GABA(A) receptor antagonists

so it’s an antidote through competitive inhibition

23
Q

what is the antidote and MOA of the antidote for opiod overdose?**

A

naloxone

antagonists at the mu opioid receptor

24
Q

what is the antidote and MOA of the antidote for TCA overdose?**

A

sodium bicarbonate

TCAs cause sodium channel blockade that results in QRS prolongation

sodium bicarbonate causes serum alkalinisation

25
Q

what is the antidote and MOA of the antidote for B-blocker overdose?**

A

glucagon

acts by directly activating adenyl cyclase by a mechanism separate from catecholamines so it bypasses beta blockade

it also increases hepatic gluconeogenesis which counteracts the hypoglycemia caused by B 2 blockade

26
Q

what is delirium?

A

disruption in the neurobiological circuitry of attention in non-dominant parietal and frontal lobes

neurotransmitter (acetylcholine, serotonin, NE, GABA, endorphins) mechanisms

pro-inflammatory cytokines

30% of older medical pts experience delirium at some point during hospitalization

surgical patients & risk of delirium: 10-70% and higher with frail pts (hip fracture, cardiac surgery)

27
Q

how do you manage delirium?

A
  1. continuity of care (nurses, techs, physicians)
  2. avoid room changes
  3. adhere to routines
  4. private or semi private room
  5. remove unnecessary equipment or clutter
  6. visible clock
  7. home management
  8. coping skills
  9. long term planning
  10. dry erase board
  11. call patient by preferred name
  12. glasses, dentures, hearing aids
  13. limit unnecessary awakenings
  14. turn lights & TV off at 10pm, and on during the day
  15. blinds open/sunlight in, during the day
28
Q

what do you do some someone has agitation with delirium?

A
  1. recognize delirium (hypoactive versus hyperactive)
  2. assess its cause
  3. treat the cause of delirium
  4. treat l difficulties of agitation from delirium

keep in mind the pharmacokinetic and pharmacodynamics issues, in addition to drug-drug interactions, QTc (450-500?), renal and hepatic functioning when choosing how to manage agitation with medications

29
Q

which medications can you use to manage delirium?

A
  1. depakote/valproate or valproate acid
  2. haldol
  3. remeron/mirtazapine (if having trouble sleeping, works on 5HT receptor, can increase appetite)
  4. buspar/buspirone
  5. clonidine
  6. trazodone

do schedule medications then additional medications as needed

adjust bowel care; make sure they’re having normal bowel movements and they’re not in pain

avoid anticholinergics that can induce even more delirium

30
Q

which drug is useful for literally any kind of agitation?

A

lorazepam = adavan

31
Q

what is NMS?

A

NMS = neuroleptic malignant syndrome

life threatening reaction that can occur in response to neuroleptic/antipsychotic medication

symptoms = high fever, sweating, confusion, rigid muscles, muscle cramps, variable blood pressure, ANS instability, fast heart rate, rhabdomyolysis, high K+, kidney failure, seizures

diagnosis is based on symptoms

can progress within 3 days

differential = heat stroke, malignant hyperthermia, other causes of delirium

risk factors = dehydration, agitation, catatonia, rapid adjusting levodopa

32
Q

what are the clinical pearls for acute agitation?*

A

if appropriate, offer oral medication first

after treatment with IM agents: monitor vitals and clinical status at regular intervals

allow adequate time for clinical response between doses

use lower starting and maximum doses in the elderly (QTc!!!) and child and adolescent population

rule-out medical complications as a potential cause of agitation (hyper- or hypoglycemia, electrolyte disturbance, renal or hepatic failure, thyroid or adrenal disorders, Wernicke’s encephalopathy, hypotension, heart failure, neurologic disorders (stroke), meningitis infection (especially in elderly), and dementia)

rule-out substance intoxication or withdrawal

rule-out medication causes of acute agitation (steroids, anticholinergics, barbiturates, amphetamines, antipsychotic-induced akathisia)

33
Q

what are the really important clinical pearls about agitation?**

A
  1. lorazepam is preferred for undifferentiated agitation (provides muscle relaxation, anxiolytic, anticonvulsant effects, and generalized sedation)
  2. haloperidol has a relatively low propensity for sedation and hypotension compared with other IM agents (such as chlorpromazine); however, it does have a higher incidence of EPS
  3. the combination of a benzodiazepine and a typical antipsychotic (i.e., haloperidol) has been shown to be superior to monotherapy with either agent and may allow for decreased doses of the antipsychotic medication. The combination can cause excessive sedation

Psych Week 3 (11 decks)

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