OSCE emergencies (Psychiatry) Flashcards
First-generation antipsychotics are associated with more side-effects that include:
- Extrapyramidal: movement disorders like parkinsonism and dystonia
- Anti-cholinergic: dry mouth, dry eyes, constipation, urinary retention
- Anti-histamine: sedating
- Cardiovascular: prolonged QT interval, arrhythmias
- Neuroleptic malignant syndrome
second-gen antipsychotics side effects
lower side effect profile
- key: weight gain and hyperlipidaemia (check lipids before startin)
still risk of
- extrapyramidal side effects
- Long QT interval
- NMS
RF for NMS
- high antipsychotic dose
- concomitnat drug use e.g. lithium
- depot
- medical illness
- previous NMS
presentation of NMS
Occurs within 2 weeks of starting
- Altered mental state (confusion)
- Fever >38 degrees
- Muscular rigidity
- Dysautonomia (autonomic instability)
o Tachycardia,
o Labile blood pressure
o Profuse sweating
o Arrhythmias
investigations for NMS
Bedside
- Obs
- Blood glucose
- GCS
- ECG
Bloods
- Uand Es
- ABG- metabolic acidosis
- LFT - derangement
- CK - critical in all suspecticed cases due to rhabodymyolysis
Imaging
- CT/MRI for alternative causes
Special
- Lumbar puncture e.g. autoimmune encephalitis
management of NMS
Largely supportive. Most episodes resolve within two weeks of removing offending drug
1) Stop causative agent
2) Determine if mild or severe case
Mild cases- supportive care
1) Cardiac monitoring
2) CK and U&Es monitoring
3) IV fluids
4) Antipyretics
5) Cooling blankets for hyperthermia
6) Antihypertensive agents
7) Benzos for agitation
Severe cases- medical therapy
1) Supportive care
2) Dantrolene: ryanodine receptor antagonist (causes skeletal muscle relaxation). Helps treat hyperthermia and rigidity.
3) Bromocriptine: dopamine agonist. Prescribed to restore ‘dopaminergic tone’.
NMS may present similarly to
Seratonin syndrome
Serotonin syndrome
similar presentation to NMS in association with selective serotonin reuptake inhibitor (SSRI) drug use.
presentation of seratonin syndrome
- nausea, vomiting, diarrhoea
- shivering
- altered mental state
- hyperreflexia
- myoclonus
- ataxia.
management of Seratonin syndrome
1) Discontinue agent
2) IV fluids
3) Benzodiazepines
delirium tremens
- Withdrawal delirium due to alcohol withdrawal
- Only occurs in people with a high alcohol intake for more than a month
presentation of delirium tremens
- cognitive impairment
- vivid pereceptual abnormalities
- tactile hallucinations e.g. bugs crawling on skin
- paranoid delusion
- marked trmor
- autonomic arousal e.g. tachy, fever, pupillary dilation, increased sweating
Signs
- dehydratio
- electrolyte disturbance
management of DT
- large dose of benzodiazepine e.g. lorazepam, chlordiazepoxide until sleeping
- haloperidol for any psychotic features
- intravenous pabrinex
o Contains thiamine (B1), riboflavin (B2), pyridoxine (B6) and nicotinamide, and also benzyl alcohol as a local anaesthetic.
wernickes
- Confusion
- Ataxia
- Oculomotor dysfunction (Nystagmus)
presentation of korsakoffs
- Chronic amnesic syndrome: Defects in Anterograde and retrograde memory
- Confabulation: stories made up to fill gaps in memory
- Poor insight: unaware of heir illness
investigations for WE
- Clinical diagnosis normally
- Cane criteria
o Dietary def
o Oculomotor dysfunction
o Altered mentals status or mild memory impairment - Neuroimaging e.g. CT to exclude alternative cause of confusion
managemnt of wernickes
Intravenous thiamine e.g. Pabrinex
- Should be give 2-3 pairs up to three times a day for 3-5 days
- Should be administered before or alongside any glucose infusion
- After initial treatment, patients should be given orqal thiamine replacement and continued until patient not at risk
At risk patients
- Pabrinex prophylactically
acute dystonia background
Extrapyramidal side effect
- An acute medication-induced dystonia- movement disorders characterised by involuntary contractions of muscles, and typically develop within minutes or hours following a trigger such as a medication.
presentation of acute dystonia
Extrapyramidal side effect within a few days of taking medication
o Onset of atypical posture or position of muscles within minutes or hours of taking medications
o Ocular muscles, jaw, tongue, face, neck and trunk of the body
management of acute dystonia
- Procyclidine hydrochloride can be given parenterally and is effective emergency treatment for acute drug-induced dystonic reactions.
- If treatment with an antimuscarinic is ineffective, intravenous diazepam can be given for life-threatening acute drug-induced dystonic reactions.
how is lithium prescribed to prevent toxicity
- Before lithium is started: UEs, TFTs, pregnancy status, ECG
Due to its side effect profile and risk of toxicity lithium is strictly regulated
- Lithium levels – 12 hours following first dose, then weekly until therapeutic level (0.5–1.0 mmol/L) has been stable for 4 weeks.
- Once stable check every 3 months.
- U&Es – every 6 months; TFTs – every 12 months.
presentation of lithium toxicity
1.5–2.0 mmol/L
- N+V
- coarse tremor
- ataxia
- muscle weakness
- apathy.
management of lithium toxicity
Supportive treatment should be initiated, which includes correction of fluid and electrolyte balance.
Clozapine induced agranulocytosis
- Antipsychotic used to treatment resistant Schizophrenia.
- Decreases neutrophil count and susceptibility to infection.
- Very effective antipsychotic but huge potential for side effects.
- Doesn’t cause extrapyramidal side effects
presentation of agranulocytosis
Occurs most frequently in the first 18 weeks of treatment
- Fever
- Sore mouth
- Sore throat
- infection
manageging neutropenia
give granulocyte colony-stimulating factor (G-CSF)
risk assessments in psych
- risk to self
- risk to others
- driving risk?
MSE
Behaviour
Mood
Speech
Thoughts
Perception
Cognition
Insight
