Lecture phase 4 Flashcards
Social Determinants?
Poverty & deprivation Social isolation / stigma Migration Unemployment Lack of meaningful activity Housing / homelessness Institutional care Racism / discrimination Criminal Justice System Education Trauma / abuse Inequality / exclusion
Interventions for social?
Statutory / LA / 3rd Sector support Care package / social prescribing Specific cultural / religious support Employment support / job centre Arts based & exercise based groups Supported housing / housing Local Authority / safeguarding Cultural advocacy / CJS Street / police triage / victim support Educational support package / SEND Self help / psychoeducation groups Social integration projects / language skills / digital inclusion
What is rapid tranquillisation??
“Use of medication by parenteral route if de-escalation & oral medication not possible or urgent sedation necessary for safety because of disturbed / dangerous behaviour”
First steps of rapid tranquillisation, before medications?
1) Differential diagnosis – OD / HI / brain disorder / substances / hypoxia
2) De-escalation techniques –voice, posture, kindness, low stimulus environment, empathy
3) Physical health checks if possible (ECG)
4) Contraindications – resp/CVS disorders
5) Support of team and appropriately trained staff for restraint
6) Discussion with seniors
Medication options for RT?
Oral – lorazepam 1-2mg / haloperidol 5-10mg + promethazine 25-50mg
IM – lorazepam 1-2mg / haloperidol 2.5 – 5 mg + promethazine 25- 50mg
Steps after RT?
- Documentation
- Physical health checks (& look for SE - dystonia, respiratory depression, urinary retention)
- Debrief with team
What is NMS? Causes?
Idiosyncratic & life threatening
Insidious (1-2/52 of start or changed dose)
All neuroleptics + other dopaminergic meds
Symptoms of NMS? Bloods?
- Neuroleptics within 1-4 weeks
- Hyperthermia (>38)
- Muscular hypoactivity & severe rigidity (lead pipe)
- Altered mental state
- Autonomic dysfunction - tachycardia, fluctuating BP, excessive sweating, tremor
- Raised CK + WCC + LFTs (raised transaminases and LDH)
- Low Fe
Also - metabolic acidosis, increased CPK or urinary myoglobin, leukocytosis
How would you manage NMS?
Medical emergency - ABCDE
- stop neuroleptics (major tranquillisers)
- correct volume depletion w/ IV fluids
- consider IV benzodiazepine
- cooling device/antipyretics for hyperthermia
What is serotonin syndrome?
Serotonin syndrome (or serotonin toxicity) is a potentially life threatening condition associated with increased serotoninergic activity in the central nervous system.
Characteristic triad of serotonin syndrome?
Sudden (within 24hrs)
1) Mental status changes
2) Autonomic hyperactivity - dilated pupils, shivering, hyperactive bowel, fever
3) Neuromuscular abnormalities - shivering, NM hyperactivity, hyperreflexia and clonus
Difference between NMS and SS?
both may have raised CK, WCC and LFTs but more obvious in NMS than SS
both have autonomic changes and altered mental state but NMS is more hypoactive whilst SS is hyper
Management of SS?
Medical emergency -
- stop SSRI
- supportive care
Causes of SS?
Increased or starting new drugs, symptoms often within 24hrs
- MOAs - selegiline
- SNRIs - duloxetine
- SSRIs - fluoxetine
Common side effects of lithium at therapeutic dose?
Rare side effects?
Signs of toxicity?
At therapeutic dose:
- Fine tremor
- dry mouth, metallic taste
- GI disturbance (diarrhoea, nausea)
- increased thirst and urination
- thyroid dysfunction
- drowsy
Rare - renal dysfunction, hypo/hyper thyroid, foetal abnormality (if 1st trimester)
Toxicity:
- coarse tremor
- CNS disturbance - seizures, coma, impaired co-ordination, shaking/muscle twitches
- arrhythmia
- visual disturbance - blurred
