Mental health emergencies

Question 1

What are psychiatric causes of psych emergencies?

Answer 1

1) Schizophrenia
2) Paranoid schizophrenia
3) Mania
4) Personality disorder - Antisocial type
5) Dementia (Behavioural emergencies)
6) Learning disability

Question 2

What are strategies to prevent violence leading to assault? (verbal assault) (Non-medical treatment of aggression)

Answer 2

1) Distraction techniques
2) Body language
3) be empathetic and calm
4) Keep Hands visible - Keeps them focussed (paranoid)
5) Keep the door open
6) Stay at least arms length from the patient
7) Use non-threatening body language
8) Use reflective statements rather than judgemental ones
9) Answer all questions softly and simply and honestly

Question 3

Pharma logical interventions is it a science or and art?

Answer 3

Think:
1) Arousal
2) Agitation
Agitation and arousal are of concern because they can lead to aggression (the threat of violence) and violence (the exercise of physical force to cause injury or damage to oneself or others property)

Helpful planning in treatment to know patients medication history, and whether agitation is occurring in the context of physical illness, mania, paranoid psychosis

Question 4

What are common medicines used in emergencies?

Answer 4

1) Benzodiazepines
2) Antipsychotics
3) Antihistamine
4) Anticholinergics

Question 5

What is serotonin syndrome?

Answer 5

• Occurs when any medication increases 5HT
• Serotonin syndrome and its spectrum of symptoms are a product of over activation of both central and peripheral serotonin receptors as a results of high levels of serotonin
• • A sudden build up of serotonin systemically may lead to a life threatening condition manifesting

What are the triad of symptoms: (3 A’s)

1) Agitation
2) autonomic instability- diarrhoea, N&V
3) Neuromuscular hyperactivity -

Question 6

Clinical Presentation of serotonin syndrome

Answer 6

1) Tremors, Hyper-rigidity, hyperreflexia, myoclonus
2) Excitement or confusion, agitation or hypervigilance, anxiety
3) Hyperthermia, diaphoresis, hypotension, tachycardia, tachypnoea (autonomic instability)

Question 7

How is SS diagnosed?

Answer 7

Diagnosis of serotonin syndrome is entirely clinical and is based on the 1) History 2) Physical examination along with history of the patients use of a serotonergic drug

Question 8

What drug can be used to help SS? What supportive care is required?

Answer 8

Cyproheptadine is the most potent 5HT2a- is an initial dose of 12mg with addition of 2mf every 2 hours
Dantrolene- A potent mucles relaxant used to treat Malignant hyperthermia is effective

Question 9

Neuroleptic malignant syndrome

Answer 9

it is hypermetabolic reaction to dopamine antagonists primarily antipsychotics drugs
Often occurs when iniating treatment vs on maintenance

Develops in up to 3 percent of patients started on antipsychotics

Its pathophysiological basis is believed to be blockade of central dopamine receptors

While symptoms usually develop during the first two weeks of antipsychotic therapy

FEVER: NMS presentation:

1) Fever
2) Encephalopathy
3) Vitals unstable (
4) Elevated enzymes (elevated CPK)
5) Rigidity of muscles

Question 10

What are risk factors for NMS?

Answer 10

Male
Antipsychotics
Patient agitation or catatonia
Prior Akathisia
Dehydration
rapid initiation or dose escalation of neuroleptics
Use of high potency agents and depot intramuscular preparations
History of organic brain syndrome or affective disorder

Question 11

What investigations are important in NMS

Answer 11

1_ Respiratory and metabolic acidosis

2) Myoglobinuria
3) Elevated CK
4) CK increase

Examination:

1) Hyperreflexia
2) Diaphoresis
3) Autonomic instability

Mortality 10-20%
Treatment is usually in ICU

1) STOP offending drugs
2) Dopamine agonist such as Bromocriptine (2.5-10mg TDS
3) Dantrolene - Skeletal muscle relaxant - Decreases rhabdo/Decreases CK release
4) Supportive therapy: Antipyretics, cooling blanket, IVF, BP control (with clonidine)
5) After recovery. reintroduction of the antipsychotic drugs retriggers the syndrome in up to 1/3 of patients

Question 12

What is delirium Tremens

Answer 12

• Caused by increased glutamate due to chronic GABA (from alcohol)
• Delirium Tremens- A withdrawal syndrome that starts within 7 days of withdrawal (usually within 24 to 72 hours)
• It is a medical emergency
• It has an anticipated mortality of up to 37 percent without treatment
• It is crucial to identify early to provide treatment

Question 13

What are risk factors for DTS

Answer 13

1) History of DT
2) Prior history of seizures (e.g drugs)
3) Prior history of detoxification
4) Prolonged period since last drink

Question 14

What is the mechanism of DT

Answer 14

1) Alcohol is a CNS depressant
2) It enhances CNS inhibition of excitatory NTs
3) Removal of alcohol, rebound

Question 15

What is Dts clinical presentation?

Answer 15

1) initial minor withdrawal symptoms - anxiety, insomnia, palpitations, headaches, GI symptoms
2) Minor withdrawal progress to alcohol hallucination, a condition charactyerized by visual hallucinations then further present with alcohol withdrawal seizure
Seizures can recur

DT is characterized by
1) Visual hallucination, Profound confusion, tachycardia, hypertension,

Question 16

What is the management of Dts

Answer 16

1) benzos (diaz)
2) parenteral thiamine
3) Maintenance fluid and electrolyte balance

Question 17

What is lithium toxicity?

Answer 17

Lithium levels have narrow therapeutic range: 0.6 to 1.0 Meq/L
Kidneys are responsible for 95% of lithium excretion
Factors increasing lithium concentraion in the body include excessive intake and impaired excretion

(in dehydration you increase levels of lithium)
Volume depletuion from diuretics, dehydration, febrile illness, or GI loss can lead to elevated lithium levels in Serum!

Kidneys treat lithium and sodium similarly

Question 18

What is the overall clinical presentation of lithium toxicity, Early on, clinical signs, treatment

Answer 18

OVERVIEW

acute overdose is usually benign if adequate hydration is maintained and renal function is normal
chronic toxicity can be difficult to manage and result in devastating neurotoxicity
CLINICAL FEATURES

acute ingestion or chronic accumulation
CNS: confusion -> coma, cerebella symptoms, seizure, basal ganglia symptoms (choreiform movements, Parkinson-like)
GIT: nausea, vomiting, bloating
CVS: syncope
RENAL: polyuria, polydipsia, renal insufficiency
NEUROMUSCULAR: peripheral neuropathy, myopathy
ENDOCRINE: hypothermia, hyperthermia
INVESTIGATIONS

Lithium level:
0.7-1.2mEq/L (therapeutic)
> 1.5mEq/L (toxic)
levels can be very high following acute ingestion, but do not correlate with outcome
as clinical features determine
MANAGEMENT

Resuscitation

A – impaired LOC -> intubate
consider whole bowel irrigation for massive acute ingestion
activated charchoal does not bind
Liberal fluid resuscitation with normal saline
Electrolytes and Acid-base

Avoid hyponatraemia as this will decrease lithium clearance
Specific Interventions

fluid therapy
renal clearance = 10-40mL/min
CRRT clearance = 20mL/min
haemodialysis if level > 3.5, severe symptoms or if conservative treatment doesn’t result in a level < 1.0 in 24 hrs (clearance = 70-170mL/min)

Question 19

Lithium toxicity:

Mild

Moderate

Severe

Answer 19

mild: Nausea and vomiting, lethargy, tremor, fatigue (serum lithium concentration between 1.2- 2.0 meq/l

Moderate: Confusion, agitation, delirium, tachycardia, hypertonia (2.0-3.0)

Severe:

Question 20

Dystonia

Answer 20

Dystonia’s is a movement disorder characterized by sustained or intermittent muscle contractions, causing involuntary movements, fixed postures or both.
The disorder may be idiopathic, hereditary, Acquired is mot commonly due to drugs, metabolic disorders CVA/TBI
Most cases of acute dystonia are caused by AP drugs

Question 21

EPS

Answer 21

• EPS is a neural network located in the brain that is part of the motor system involved in the coordination of movement where both sensory and motor information travels
• Major parts of include Basal ganglia

Question 22

What is the basal ganglia? Functions?

Answer 22

The basal ganglia belong to extrapyramidal system of the brain
Functions: Motor control, cognition, emotions and learning.

Parts:

1) Putamen
2) caudate nucleus
3) globus pallidus
4) nucleus accumbens

Question 23

How can Dystonia’s be classified based on their patterns:

Answer 23

Blepharospams: is a type of dystonia that affects the yes, usually begins with uncontrollable blinking

Cervical dystonia’s: Of torticollis, is the most common type, Typical in middle aged, affects neck mucles causes head to twist and turn or be pulled backward or forward

Oromandibular dystonia:
- Causes spasms of the jaw, lips, tongues muscles

Question 24

What is the treatment of dystonias?

Answer 24

Anticholinergic drugs:

1) Benzotropine 2mg IM q15-30 min (up to 8 mg)