Psych Emergencies Flashcards
What are factors assoc w/ pt violence?
- male
- hx of violence
- drug or alcohol abuse
Signs of impending violence?
- provocative behaviro
- angry demeanor
- loud, aggressive speech
- tense posturing
- frequently changing body position
- aggressive acts
Dxs assoc w/ violence? (FIND ME)
- 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
Management of a violent pt? (verbal techniques)?
- 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
Indications for physical restraints?
- 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
3 classes of meds use as chemical restraints?
- benzos
- 1st gen antipsychotics: haldol
- 2nd gen: resperdol, seroquel
When are benzos preferred as the chemical restraint?
- 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
1st gen antipsychotics used as chemical restraint? When should you avoid these?
- 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
2nd gen antipsychotics used as chemic restraints?
- 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
For severely violent pts reqring immediate sedation - what should be given?
- 1st gen or /+ benzo
For pts w/ agitation from drug intoxication - what should be given?
- benzo
For pts w/ undiff agitation what should be given?
- benzos preferred but 1st gen AP can be used
For agitated pts w/ known psych disorder what should be given?
- 1st or 2nd gen AP
What should be included in post-restraint medical eval?
- 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)
Presentation of AIDS encephalopathy? MC etiologies?
- 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
What is psychosis?
- 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
Psychosis occurs in what disorders?
- 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
Eval of pt presenting w/ psychosis?
- 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
What are the adverse effects of cocaine use?
- 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
Withdrawal sxs of cocaine?
- prominent psych features: depression, anxiety, fatigue, difficulty concentrating, craving cocaine, increased sleep, increased appetite
- physical sxs: minor and rarely reqr tx, arthralgias, tremor, chills
Tx of cocaine withdrawal?
- 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
S/S of overdose/intoxication of meth?
- tremor
- muscle twitch
- tachypnea
- tachycardia
- hallucinations
- aggressive behavior
- sweating, convulsions
- panic
- agitated
Meth is assoc w/ why psych sxs? Dx?
- paranoia, psychosis, and delusions
- homicidality and suicidality
- mood disturbances
- anxiety and hallucinations
- dx: sympathomimetic toxidrome, diff it from cocaine and PCP
Eval of meth intoxication? Labs?
- complications: hypovolemia, metabolic acidosis, hyperthermia, and rhabdo
- check:
lytes
lactaet
CK
aminotraferases
clotting times
renal fxn
ABG s
Tx of meth intoxication?
- 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
Meth tx pitfalls?
- 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
What is neuroleptic malignant syndrome (NMS)? Sxs?
- 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
When does NMS usually develop?
- 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
DDx for NMS?
- 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
Dx NMS?
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)
Tx of NMS?
- 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
Intense aggressive and supportive care for NMS tx is aimed at preventing?
- dehydration
- lyte disturbance
- ARF assoc w/ rhabdo
- cardiac arrhythmias and arrest
- MI
- cardiomyopathy
- resp failure, aspiration pneumonia, PE
- DVT
- DIC
- seizures
- hepatic failure
- sepsis
Goals of alcohol withdrawal tx?
- manage sxs of withdrawal
- prevent serious events
- bridge pts to tx for recovery
When do alcohol withdrawal seizures take place?
- 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
When does alcoholic hallucinosis occur?
- 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
When do delirium tremens occur?
- 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
Assessment and management of DTs?
- 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
Presentation of acute ethanol intoxication?
- 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!
What are panic attacks? what medical disorders need to be r/o?
- 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
Hx questions to ask pt presenting w/ panic attack?
- life stressors
- pt concerns and fears
- recent substance abuse
- PE: full exam
- dx testing: lytes, thyroid screen, chem panel
Sxs of depression? What do you always need to ask about?
- 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
Evaluation for suicide risk?
- 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
Schizophrenic disorders presents as?
- w/ psychosis and deterioration in fxnl capacity
- MSE, ask about harming self or others
- PE : ask about hallucinations, delusions, ideas of reference
Lab tests to order for schizophrenic disorders?
- 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
Tx of schizophrenic disorders?
- 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
Paranoid state - tx?
- 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
S/S of catatonia?
- 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
Etiologies of catatonia?
- major depression
- manic episode
- epilepsy
- encephalitis
- meds: APs, benzos withdrawal
- misc:
hepatic encephalopathy, SLE, wilson’s, lyme disease
DDx for catatonia?
- NMS
- serotonin syndrome
- malignant hyperthermia
- nonconvulsive status epilepticus
- parkinson disease
- stroke
- delirium
- dementia
Tx of catatonia?
- 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
S/S of manic state? Management?
- 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
What is conversion disorder?
- 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
What is somatization?
- 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
What is serotonin syndrome?
- 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
Dx of serotonin syndrome?
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
Tx of serotonin syndrome?
- 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
Meds that may contribute to serotonin syndrome?
- 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
What is prereq for involuntary psych admission?
- 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
What disorders does the term mentally ill include?
- 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
Types of involuntary hospitalization?
- 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
When do you use Benzos in ER? SEs?
- 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
Signs of OD of benzos?
- 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
SEs of first gen APs?
- 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)
2nd gen APs used? Indications? Ses?
- Risperidone
- olanzapine (zyprexa)
- quetiapine (seroquel)
- approved for tx of:
schizophrenia
acute bipolar mania
acute agitation - primary SE:
sedation
hypotension
NMS
sudden death