Psychiatric Emergencies

Question 1

Managing acutely disturbed patients

-before seeing the patient

Answer 1

Current risks?
Immediate worries?
Are there any triggers or stressors?
-rule out organic/intoxication

Psych history => past violent behaviour?
Legal status => do they need detention under S5(2)

Review patient in suitable safe environment with staff with a good rapport with the patient

Question 2

Managing acutely disturbed patients

-verbal deescalation

Answer 2

Address them by name
Calm and firm manner
Don’t raise your voice

Regular eye contact
Non aggressive posture
Suitable distance

Try to address their concerns and offer support
Do not make false promises

Question 3

Managing acutely disturbed patients

-medical deescalation

Answer 3

Offer PO

• BZ
• fast acting antipsychotic (haloperidol, promethazine)

If refused and are a risk to self and others => IM lorazepam/midazolam with haloperidol/procyclidine
-restraint used if needed

Regular physical observations needed after tranquilisation

Question 4

When would you consider supervised confinement

• what is it
• what do you need before this can be implemented

Answer 4

Severe risk to self or others and are not manageable on the ward with verbal or medical interventions

Nursed in isolation with regular medical review

Must be in PICU + under section

Question 5

What are extrapyramidal side effects

• when do you see them
• describe the main 4

Answer 5

Commonly seen in

• antipsychotic naive patients
• high doses
• typical antipsychotics

Acute dystonias - painful sustained muscle contractions => abnormal posturing

Oculogyric crisis - sudden facial, jaw, neck spasm with eyes rolling upwards

Parkinsonian - rigidity, bradykinesia, shuffling gait

Tardive dyskinesia - involuntary repetitive movements
-often in tongue and face

Question 6

Management of EPSE

• acute dystonias, oculogyric crisis
• Parkinsonism
• tardive dyskinesia

Answer 6

Acute dystonia, oculogyric crisis => short term procyclidine

Parkinsonism => long term procyclidine

Tardive dyskinesia => stop neuroleptic medication

Review antipsychotics
-trial atypicals if possible

Question 7

What is neuroleptic malignant syndrome

• who is it most common in
• management

Answer 7

Life threatening GRADUAL neurological reaction in response to antipsychotics

• young men
• depot
• antipsychotic naive

Tetrad of

• fever, sweating
• leadpipe rigidity => high CK
• altered mental state - confusion agitation
• autonomic instability - high BP, HR, RR

Stop antipsychotics and document => acute care transfer

• hydration
• temperature control
• BZ for agitation

Question 8

What is serotonin syndrome

Answer 8

Life threatening ACUTE adverse drug reaction => elevated seretonin

Tetrad

• fever, sweating
• hypertonia, hyperreflexia, tremos
• altered mental state - confusion, agitation
• autonomic instability - high BP, HR, RR

Stop all responsible drugs
BZ for agitation, reduce muscle spasms
Supportive - hydration, temperature control