Psych Emergencies Flashcards
1
Q
What are factors assoc w/ pt violence?
A
- male
- hx of violence
- drug or alcohol abuse
2
Q
Signs of impending violence?
A
- provocative behaviro
- angry demeanor
- loud, aggressive speech
- tense posturing
- frequently changing body position
- aggressive acts
3
Q
Dxs assoc w/ violence? (FIND ME)
A
- Fxnl: psych (schizophrenia, paranoid, cataonic, mania) miscommunication (fear of rejection, dependecy, illness)
- Infectious: CNS, meningiits, encephalitis, sepsis
- Neuro: head injury/hemorrhage, postictal states, vasculitis, neoplasm
- Drug related: alcohol, amphetamines, PCP, LSD, steroids
- Metabolic: lyte abnorm, hypothermia/hyperthermia/ anemia, vit def (B, folate), wernicke’s encephalopathy, hypoxia
- Endocrine: hypoglycemia, thyroid storm, cushing’s disease
4
Q
Management of a violent pt? (verbal techniques)?
A
- remove pt from contact w/ provocative pts
- expedite eval
- verbal techniques: address violence directly, set limits, don’t be provocative, be honest and straightforward, calm and soothing tone of voice, simple language, offer choices and optimism, stand at least 1 arm’s length away, ID feelings and desires, take all threats, seriously, and protect yourself
5
Q
Indications for physical restraints?
A
- if verbal techniques are not working and escalation occurs - get help!
- use of restraints can be humane and effective, can help w/ dx and tx, remove ASAP, usually when chemical restraint is achieved
- indications:
imminent harm to others, to self, sig disruption of impt tx or damage to enviro - continuation of effective, ongoing behavior tx plan
- should have 5 person restraint team, if female pt - one member must be female
- once pt is restrained needs to be monitored closely: position, resp, avoid aspiration
- documentation is rqd
6
Q
3 classes of meds use as chemical restraints?
A
- benzos
- 1st gen antipsychotics: haldol
- 2nd gen: resperdol, seroquel
7
Q
When are benzos preferred as the chemical restraint?
A
- when sedating pts when agitated from unknown cause
- lorazepam and midazolam (shorter half life): both PO, IM, IV
- can cause resp depresssion: monitor closely!!
- can be used w/ first gen antipsychotic
8
Q
1st gen antipsychotics used as chemical restraint? When should you avoid these?
A
- haloperidal (PO, IM)
- droperidol (IM, IV) - BBW prolong QT
- both cause QT prolong w/ potential causing dysrthymias (torsades)
- avoid:
cases of EToH withdrawal
benzo withdrawal
other w/drawals
anticholinergic toxicity
pts w/ seizures
pregnant and lactating females
9
Q
2nd gen antipsychotics used as chemic restraints?
A
- olanzapine (zyprexa)
- risperidone (risperdal)
- ziprasidone (Geodon)
- less sedation and fewer extrapyramidal side effects
- less experience using them so benzos and 1st gen antipsychotics first choice
10
Q
For severely violent pts reqring immediate sedation - what should be given?
A
- 1st gen or /+ benzo
11
Q
For pts w/ agitation from drug intoxication - what should be given?
A
- benzo
12
Q
For pts w/ undiff agitation what should be given?
A
- benzos preferred but 1st gen AP can be used
13
Q
For agitated pts w/ known psych disorder what should be given?
A
- 1st or 2nd gen AP
14
Q
What should be included in post-restraint medical eval?
A
- complete set of VS including pulse ox
- thorough mental status and neuro exams
- rapid blood glucose determination
- r/o acute medical condition (brain bleed for ex)
15
Q
Presentation of AIDS encephalopathy? MC etiologies?
A
- presentation: change in mental status, abnorm neuro exam
- must determine degree of immunosuppression
- MC etiologies:
toxoplasmosis encephalitis
primary CNS lymphoma
progressive multifocal leukoencephalopathy, HIV encephalopathy, CMV encephalitis
16
Q
What is psychosis?
A
- disturbance in perception of reality, evidenced by hallucinations, delusions, or though disorganization. Psychotic states are periods of high risk for agitation, aggression, impulsivity and other forms of behavioral dysfxn
17
Q
Psychosis occurs in what disorders?
A
- schizophrenia
- bipolar mania
- major depression w/ psych features
- schizoaffective disorder (depression or mania occurs and then psychosis occurs at sep time)
- alzheimers
- delirium
- substance induced psychotic disorder
- psychosis secondary to medical condition
18
Q
Eval of pt presenting w/ psychosis?
A
- MSE: mini mental, observation of pt - med eval: VS (including pulse ox) PE chem panel CBC thyroid fxns UA drug screen add testing as indicated
19
Q
What are the adverse effects of cocaine use?
A
- anxiety/irritability
- panic attacks
- suspiciousness/paranoia
- grandiosity/impaired judgement
- psychotic sxs: delusions/hallucinations
- physical sx due to SNS stim:
tachycardia, tachypnea, HTN, hyperthermic, diaphoretic, dilated pupils
20
Q
Withdrawal sxs of cocaine?
A
- prominent psych features: depression, anxiety, fatigue, difficulty concentrating, craving cocaine, increased sleep, increased appetite
- physical sxs: minor and rarely reqr tx, arthralgias, tremor, chills
21
Q
Tx of cocaine withdrawal?
A
- mainly supportive
- allow pt to sleep and eat as needed
- no meds shown to help
- hosp mainly for psych sxs
- determining d/c: psych eval for tx addiction, usually tx as outpt, so if cleared medically and by psych can be d/c
22
Q
S/S of overdose/intoxication of meth?
A
- tremor
- muscle twitch
- tachypnea
- tachycardia
- hallucinations
- aggressive behavior
- sweating, convulsions
- panic
- agitated
23
Q
Meth is assoc w/ why psych sxs? Dx?
A
- paranoia, psychosis, and delusions
- homicidality and suicidality
- mood disturbances
- anxiety and hallucinations
- dx: sympathomimetic toxidrome, diff it from cocaine and PCP
24
Q
Eval of meth intoxication? Labs?
A
- complications: hypovolemia, metabolic acidosis, hyperthermia, and rhabdo
- check:
lytes
lactaet
CK
aminotraferases
clotting times
renal fxn
ABG s
25
Q
Tx of meth intoxication?
A
- control agitation w/ benzos or w/ 2nd Gen AP
- physical restraints are undesirable
- succinylcholine is CI
- control hyperthermia, fluid resuscitation
- HTN: tx w/ nitroprusside or phentolamine, avoid BBs
- use of activaed charcoal is rarely indicated
26
Q
Meth tx pitfalls?
A
- failure to respect agitation and potential for violence
- failure to tx hyperthemia
- failure to recognize rhabdo (release of CK)
- failure to consider assoc illness and trauma
- failure to note risk of contamination of drug ingestion
27
Q
What is neuroleptic malignant syndrome (NMS)? Sxs?
A
- life threatening neuro emergency assoc w/ use of neuroleptic agents:
most often seen w/ first gen high potency agents, q class has been implicated including antiemetic drugs (metoclopramide, promethazine, compazine) - sxs:
mental status change
muscular rigidity
hyperthermia
autonomic instability
28
Q
When does NMS usually develop?
A
- w/in 1st 2 wks of therapy
- can develop any time
- higher doses are a RF
- can be seen in pts where anti-parkinsonian meds are withdrawn: Neuroleptic malignant like syndrome
29
Q
DDx for NMS?
A
- serotonin syndrome: N/V/D, hyperreflexia, myoclonus
- malignant hyperthermia
- malignant catatonia
- acute intoxication w/ cocaine and ecstasy (rigidity not common)
- neuro and medical disorders:
infections
seizures
acute spinal cord injury
heat stroke
thyrotoxicosis
withdrawal states
30
Q
Dx NMS?
A
most of the tests r/o other conditions:
- MRI or CT of brain
- LP
- CBC
- chem panel
- EEG: r/o seizures
- tox screen
- CK elevation (4x upper limit of normal)
31
Q
Tx of NMS?
A
- only + dx test is elevated CK (over 1000 IU/L)
- STOP the causative agent
- other potential psychotropic agents also should be stopped
- if do to dopamine withdrawal - restart it
32
Q
Intense aggressive and supportive care for NMS tx is aimed at preventing?
A
- dehydration
- lyte disturbance
- ARF assoc w/ rhabdo
- cardiac arrhythmias and arrest
- MI
- cardiomyopathy
- resp failure, aspiration pneumonia, PE
- DVT
- DIC
- seizures
- hepatic failure
- sepsis
33
Q
Goals of alcohol withdrawal tx?
A
- manage sxs of withdrawal
- prevent serious events
- bridge pts to tx for recovery
34
Q
When do alcohol withdrawal seizures take place?
A
- 12-48 hrs after last drink
- more common in pts w/ long hx of chronic alcoholism
- usually singular or several over short period
- tx w/ benzos and if necessary phenobarbital
35
Q
When does alcoholic hallucinosis occur?
A
- develop w/in 12-24 hrs after last drink and resolve w/in 24-48 hrs
- usually visual but auditory and tactile can occur
- no clouding of sensorium and VS normal
- supportive therapy
36
Q
When do delirium tremens occur?
A
- begins b/t 48-95 hrs after last drink and can last 1-5 days
- mortality rate of 5%
- s/s:
hallucinations
disorientation
agitation
tachycardia, HTN, fever
diaphoresis
these all lead to problems w/ fluid and lytes status
37
Q
Assessment and management of DTs?
A
- r/o alt dx (subdural hematoma, meningitis)
- control sxs/ supportive care:
benzos, IV fluids, nutritional supp: K+, magnesium, thiamine - close monitoring: sometimes ICU
- if high dose benzos not working for DTs: can add phenobarbital, don’t give antipsychotics b/c lowers seizure threshold
38
Q
Presentation of acute ethanol intoxication?
A
- dx of exclusion: presents w/ changes in mental status: hypoglycemia hypoxia head trauma poisoning by other agents - serum ethanol conc don't correlate closely w/ sxs - when dx is made: tx is supportive - thiamine to prevent Wernickes!
39
Q
What are panic attacks? what medical disorders need to be r/o?
A
- characterized by sudden onset of intense fear and by abrupt development of specific somatic, cognitive and affective sxs
- R/O medical disorders:
angina
arrhythmias
COPD/asthma
temporal lobe epilepsy
PE
hyperthyroidism
pheochromocytoma
40
Q
Hx questions to ask pt presenting w/ panic attack?
A
- life stressors
- pt concerns and fears
- recent substance abuse
- PE: full exam
- dx testing: lytes, thyroid screen, chem panel
41
Q
Sxs of depression? What do you always need to ask about?
A
- sxs:
anhydonia, lethargy, early morning awakening, change in appetite, poor hygeine, decreased libido, poor concentration: for longer than 6 wks - always aks about suicidal, homicidal, and manic states
- r/o medical cause
42
Q
Evaluation for suicide risk?
A
- presence of suicidal or homicidal ideation, intent, or plan
- access to means for suicide and lethality of those means
- presence of psychotic sx, command hallucinations, or severe anxiety
- presence of alcohol or other substance use
- hx and seriousness of previous attempts
- family hx of or recen exposure to suicide
- degree of hopelessness and impulsivity
- have to reduce immediate (hosp maybe), manage underlying factors, monitor and f/u
43
Q
Schizophrenic disorders presents as?
A
- w/ psychosis and deterioration in fxnl capacity
- MSE, ask about harming self or others
- PE : ask about hallucinations, delusions, ideas of reference
44
Q
Lab tests to order for schizophrenic disorders?
A
- CMP
- tox screen
- chem panel
- may need:
if indicated by hx or PE:
MRI of CT of head
heavy metal screen
EEG
tests for Hep C, HIV
45
Q
Tx of schizophrenic disorders?
A
- agitated pt: safety
- psychosis alone doesn’t meet legal criteria for involuntary tx
- tx:
injectable antipsychotics, some of 2nd gen AP come as orally disintegrating tabs for coop pt
46
Q
Paranoid state - tx?
A
- may occur w/ other psych illnesses
- depending on particular paranoia and illness may be tx w/ meds may or may not rqr involuntary hosp.
- clear medically for delirium, other cog dysfxnl medical conditions
- consuly w/ psych
47
Q
S/S of catatonia?
A
- immobility
- stupor
- mutism or incomprehnsible phrases
- muscular rigidity w/ waxy flexibility
- posturing
- staring
- more rarely:
negativism
automatic obedience
(will mimic what you do)
-it is a behavioral syndrome inability to move normally despite physical capacity to do so
48
Q
Etiologies of catatonia?
A
- major depression
- manic episode
- epilepsy
- encephalitis
- meds: APs, benzos withdrawal
- misc:
hepatic encephalopathy, SLE, wilson’s, lyme disease
49
Q
DDx for catatonia?
A
- NMS
- serotonin syndrome
- malignant hyperthermia
- nonconvulsive status epilepticus
- parkinson disease
- stroke
- delirium
- dementia
50
Q
Tx of catatonia?
A
- tx underlying cause:
usually occurs in context of underlying psych disordrer, may be precipitated by general medical disorder - supportive
- lorazepam
- ECT: mortality may increase if not begun w/in 5 days of sx onset
51
Q
S/S of manic state? Management?
A
- no sleep, risky behavior: gambling, sex, spending money carelessly, feel good - on a high, productive
- management:
d/c antidepressants, eval and tx substance abuse, drugs used to induce remission:
lithium carbonate: (need to check BUN, creatinine, thyroid fxn, preg test, EKG for pts over 40)
anticonvulsants
antipsychotics
benzos - ECT
52
Q
What is conversion disorder?
A
- neuro sxs that are inconsistent w/ neuro disease, but causes distress, and/or impairment
- psych comorbidity is common
- in ER: do full H and P: neuro and reassure pt, do CT scan if something abnormal or pt is freq ER pt, refer to psych
53
Q
What is somatization?
A
- syndrome of nonspecific physical sxs that are distressing
- may not be fully explained by known medical condition after appropriate investigation
- sxs may be caused/exacerbated by:
anxiety
depression
interpersonal conflict - may be conscious or unconscious
- may be influenced by a desire for sick role or for personal gain
- management:
take thorough H and P!
testing, look for possible malingering, never give narcotics! - try redirecting pt, refer to psych
54
Q
What is serotonin syndrome?
A
- potentially life threatening
- increased serotonergic activity in CNS
- etiologies: occurs over hours, usually resolves w/in 24 hrs
- spectrum of sxs:
mental status changes, autonomic hyperactivity, neuromuscular abnorm: hyperreflexia
55
Q
Dx of serotonin syndrome?
A
Hunter criteria:
- must be taking serotonergic agent
- and meet 1 of the following criteria:
- spontaneous clonus
- inducible clonus + agititation or diaphoresis
- ocular clonus + agitation or diaphoresis
- tremor plus hyperreflexia,
- hypertonia + temp above 38C + ocular clonus or inducible clonus
56
Q
Tx of serotonin syndrome?
A
- d/c of serotonergic agent
- supportive care:
O2
IV hydration
cont monitoring: normalizing VS - sedation w/ benzos
- control of hyperthermia: elim excessive muscle activity
- admin of serotonin antagonists (only given if pt severely affected):
cyproheptadine (periactin)
antihistamine w/ nonspecific serotonergic antagonist properties
57
Q
Meds that may contribute to serotonin syndrome?
A
- analgesics: codeine, fentanyl, tramadol
- abx: linezolid
- antidepressants: SSRIs, SNRIs, TCAs, MAOIs, bupropion
- dopamine agonists: levodopa, amantadine
- triptans: sumatriptan
- herbal: st johns wort, ginseng
- drugs of abuse: amphetamines, cocaine, ectasy, LSD
- misc: lithium
58
Q
What is prereq for involuntary psych admission?
A
- varies state to state
- pt must have mental illness
- other criteria freq used:
dangerous behavior towards self or others
inability to adequately care for self
59
Q
What disorders does the term mentally ill include?
A
- varies
- statutes don’t include specific psych dxs
- they define mental illness in terms of its effect on individual’s thinking or behavior
- most include some deleterious effect of illness and many include aspects of dangerousness
- some states exclude certain disorders: alcoholism, drug addiction, epilepsy
60
Q
Types of involuntary hospitalization?
A
- emergency detention: can be initiated by: another adult, police, physician, generally brief: from 24 hrs to 1-3 days
- observational commitment: usually limited to physicians/hosp personnel, many states reqr court approval
- extended commitment: formal application/sometimes 2 physicians, involves a hearing
61
Q
When do you use Benzos in ER? SEs?
A
- tx of alcohol or sedative withdrawal
- acute agitation
- acute mania or agitated psychosis
- control drug induced hyperexcitable states (Meth, PCP)
SEs:
- sedation
- lethargy
- ***resp depression
- impaired psychomotor skills and judgement
- cog dysfxn
- delirium (esp in elderly) - use haldol
- ataxia
- exacerbation of COPD, sleep apnea
- CV instability
- death
62
Q
Signs of OD of benzos?
A
- slurred speech
- incoordination
- unsteady gait
- impaired attention or memory
- severe overdose or in combo w/ other CNS drugs:
leads to stupor
can lead to coma
63
Q
SEs of first gen APs?
A
- aka neuroleptics
- chlorpromazine
- haloperidol
- w/ long term use - have high risk of parkinsonian EPS:
rigidity
bradykinesia
tremor - can increase prolactin: causing galactorrhea and amenorrhea
- other SEs:
NMS
prolong QT
sudden death - used for sedation and control of psychosis in emergent situations (MI)
64
Q
2nd gen APs used? Indications? Ses?
A
- Risperidone
- olanzapine (zyprexa)
- quetiapine (seroquel)
- approved for tx of:
schizophrenia
acute bipolar mania
acute agitation - primary SE:
sedation
hypotension
NMS
sudden death
