L13: Psychiatric Emergencies Flashcards
Introduction of Psychiatric Emergencies
- Psychiatric emergency is any disturbance in thoughts’, feelings’, or actions’ that requires immediate treatment e.g. violence, suicide, and NMS.
- Emergencies can occur in any location: Home, Office, Street, Hospitals.
Def of Suicide
if successful, it is a fatal act that fulfills the person’s wish to die.
What is Deliberate self-harm?
Willful self-inflicting of painful, destructive, or injurious acts without intent to die.
Identification of the potentially suicidal patient is among the most critical tasks in psychiatry.
…
What is Suicide?
Self-inflicted death with explicit or implicit evidence that the person intended to Die.
What is Suicide attempt?
Self-injurious behavior with a nonfatal outcome accompanied by evidence that the person intended to die
What is Aborted suicide attempt?
Potentially self-injurious behavior in which the person intended to die but stopped the attempt before physical damage occurred.
What is Suicidal intent?
Subjective expectation and desire for a self-destructive act to end in death.
What is Suicidal ideation?
Thought of serving as the agent of one’s own death; seriousness may vary depending on the specificity of suicidal plans and the degree of suicidal intent.
What is Lethality of suicidal behavior?
Objective danger to life associated with a suicide method or action.
lethality is distinct from and ……… an individual’s expectation of what is medically dangerous.
not always coincide with
Suicide Epidemeology
Etiology of Suicide
Relation between mental Ilnesses & Suicide
- Depressive Disorders
- Schizophrenia
- Alcohol & Substance Use Disorder
- Personality Disorders
- Dementia & Delirium
- Anxiety
Mood disorders are the diagnoses most commonly associated with ……
suicide
…. of all persons who commit suicide are depressed.
50%
….. of depressed patients kill themselves.
15%
Patients with ………. are at the highest risk.
mood disorder accompanied by panic or anxiety attacks
The onset of schizophrenia is typically in adolescence or early childhood, and most of these patients who commit suicide do so during ……..
the first few years of their illness.
In the United States, an estimated ….. schizophrenic patients commit suicide each year.
4,000
….. of persons who commit suicide are schizophrenic with prominent delusions.
10%
Patients who ……….. are at increased risk.
have command hallucinations telling them to harm themselves
Alcohol dependence increases the risk of ……., especially if the person is also ………
- Suicide, Depression
Studies show that many alcohol dependent patients who eventually commit suicide are rated …….. during hospitalization and that up to …….. are assessed as having mood disorder symptoms during the period in which they commit suicide.
depressed, two-thirds
Borderline personality disorder is associated with a high rate of …….
para-suicidal behavior.
The suicide rate for persons who are heroin dependent or dependent on other drugs is approximately ……. than the rate for the general population.
20 times higher
Antisocial personality disorder: …… of patients commit suicide, especially those in prisons.
5%
…… have the highest suicide rate of any group.
Prisoners
…….. risk of suicide in patients with dementia and delirium, especially secondary to alcohol abuse or with psychotic symptoms.
Increased
Unsuccessful suicide attempts are made by almost …… of patients with a panic disorder and social phobia.
20%
- If depression is an associated feature to anxiety, the risk of suicide ……..
Rises
Panic disorder has been diagnosed in ….. of persons who successfully kill themselves.
1%
Risk factors of suicide
Most important risk factor is
presence of previous suicidal attempts.
Managment of Suicide
If history of impulsive behavior, suicidal plan in action and/or absence of strong social support
Immediate hospitalization.
Patient commitment to call if his self control weakened
Check for available support and follow up at home.
Many psychiatrist view that patient with any attempt should be hospitalized.
……….
Patient refuse to give commitment
Admit immediately to inpatient clinic, advise the family if refused they should be watching him for 24h/day and call doctor at any point of real risk.
Psychiatric Preventive Measures of Suicide
- Reduce psychological pain by modifying the environment.
- Build realistic support.
- Offer alternative to suicide.
Psychiatrc Managment of Suicide
Doctor’s Responsability in suicide
Clinical Hints: Suicide
Signs of impending violence
- Very recent act of violence.
- Verbal or physical threat.
- Carrying weapons.
- Progressive psychomotor agitation.
- Alcohol or drug intoxication.
- Paranoid features in psychotic patient.
- Violent command auditory hallucinations.
- Brain disease.
- Catatonic and manic excitements.
- Agitated depression.
- Personality disorder.
general Strategy in Evaluating Emergency Situations
Tools of Interventions in Emergency TTT
Clinical Hints in violence
How to Prevent Violence Towards the Others?
managment of Violent Patient
Def of Neuroleptic malignant Syndrome
Life-threatening complication that can occur anytime during the course of antipsychotic treatment.
Symptoms of Neuroleptic malignant Syndrome
Lab Findings in Neuroleptic malignant Syndrome
Risk factors for Neuroleptic malignant Syndrome
Course & Prognosis of Neuroleptic malignant Syndrome
- The symptoms usually evolve over 24 to 72hours.
- The untreated syndrome lasts 10 to 14 days.
- The diagnosis is often missed in the early stages, and the withdrawal or agitation may mistakenly be considered to reflect an exacerbation of the psychosis.
TTT of Neuroleptic malignant Syndrome
- Supportive Measures
- ECT
- Medications
Supportive measures in Neuroleptic malignant Syndrome
- They are aimed at preventing further complications and maintaining organ function.
- Patients should receive circulatory and ventilatory support as needed.
- Cooling blankets and antipyretics can be used to control temperature.
- Aggressive fluid resuscitation and alkalization of urine can help prevent acute renal failure and enhance excretion of muscle breakdown products.
ECT in TTT of Neuroleptic malignant Syndrome
ECT has been proposed as a treatment based on its effectiveness in acute lethal catatonia
Medications in TTT of Neuroleptic malignant Syndrome
- Dantrolene (Dantrium)
- Bromocriptine (Parlodel)
MOA of Dantrolene (Dantrium)
Stimulates muscle relaxation.
Adult Dose of Dantrolene (Dantrium)
- 100-200 mg/d PO, not to exceed 400 mg/d.
- 0.8-2.5 mg/kg IV q6h, not to exceed 10 mg/kg/d.
pediatric Dose of Dantrolene (Dantrium)
- 0.5 mg/kg IV bid initially; increase to 0.5 mg/kg bid/qid,
- followed by increments of 0.5-3 mg/kg bid/qid prn,
- not to exceed 100 mg gid.
MOA of Bromocriptine (Parlodel)
Strong dopamine D2 receptor agonist and partial dopamine D1 receptor agonist.
Method of adminstration of Bromocriptine (Parlodel)
Often administered with oral dantrolene.
Adult dose of Bromocriptine (Parlodel)
5-10 mg PO bid, initial; not to exceed 40 mg/d
Pediatric dose of Bromocriptine (Parlodel)
Not established
Bromocriptine and amantadine possess …….. effects and may serve to overcome the antipsychotic-induced dopamine receptor blockade.
direct dopamine receptor agonist
The lowest effective dosage of antipsychotic drug should be used to reduce the chance of neuroleptic malignant syndrome.
….
Antipsychotic drugs with anticholinergic effects seem …… likely to cause neuroleptic malignant syndrome.
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