psychiatric emergencies Flashcards
Major psychiatric emergencies
Suicidal patients
Agitated and violent patients
Other psychiatric emergencies
Grief reaction
Rape
Disaster
Panic attacks
Medical emergencies in psychiatry
Delirium
Neuroleptic Malignant Syndrome
Serotonin syndrome
Overdose of common psychiatric medications
Overdose and withdraw from addicting substance
Clinical features of delirium
Abrupt onset and fluctuating course
- Clouding of consciousness (reduced clarity of awareness of environment, with reduced ability to focus, sustain or shift attention)
- Disturbed cognition, with impaired immediate recall and recent memory but relatively intact remote recall, and disorientation in time, place or person
At least one of the followings: variable activity levels, increased reaction time, altered flow of speech or enhanced startle reaction
At least another one of the followings:
insomnia, daytime drowsiness, reversal of sleep–wake cycle, nocturnal worsening of symptoms or disturbing dreams and nightmares
Types of delirium
Hyperactive delirium: a subtype of delirium characterised by people who have heightened arousal and can be restless, agitated or aggressive.
Hypoactive delirium: a subtype of delirium characterised by people who become withdrawn, quiet and sleepy.
Mixed delirium
Delirium superimposed on Dementia
Persistent delirium
Assessment
History
Physical exam and investigations
Risk assessment
BAseline cognitive examination: (AMT, MoCA, MMSE)
Investigations for delirium
Infection: cultures, urinalysis, FBC, CRP, CXR
Medications: review all
Metabolic/endocrine : urea and electrolytes, LFT, calcium, glucose, TFT
ECG, Hypoxia O2 sat
Neurological: CT/MRI brain
Causes for delirium
I WATCH DEATH
I Infection: HIV, sepsis, pneumonia
W Withdrawal: Alcohol, barbiturate, sedative e.g. hypnotic
A Acute metabolic: Acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure
T Trauma : Closed-head injury, heat stroke, postoperative, severe burns
C CNS pathology: Abscess, haemorrhage, hydrocephalus, subdural hematoma, Infection, seizures, stroke, tumours, metastases, vasculitis, encephalitis, meningitis, syphilis
H Hypoxia: anaemia, carbon monoxide poisoning, hypotension, pulmonary or cardiac failure
D Deficiencies: Vitamin B12, folate, niacin, thiamine
E Endocrinopathies: Hyper/hypoadrenocorticism, hyper/hypoglycemia, myxedema, hyperparathyroidism
A Acute vascular: Hypertensive encephalopathy, stroke, arrhythmia, shock
T Toxins or drugs: Prescription drugs, illicit drugs, pesticides, solvents
H Heavy Metals: Lead, manganese, mercury
Warning signs for violent behaviours
Angry facial expression
Restless or pacing
Shouting
Pronged direct eye contact
Refusal to cooperate
Presence of delusions or hallucination with violent content
Verbal threats or reports thoughts of violence
Blocking escape routes
Evidence of arousal (sympathetic nervous system activation)
Medications used for rapid tranquillisation
Benzodiazepines (lorazepam)
Antipsychotics
Combination of the above
PRomethazine
Benzodiazepines in order of increasing time it taks
es ro act
Lorazepam
Midazolam
Diazepam
What antipsychotics used to reduce agitation
Haloperidol
Olanzapine
Symptoms of neuroleptic malignant syndrome
Fever, diaphoresis (sweating), rigidity, confusion and fluctuating consciousness
Autonomic instability can present as fluctuating BP, tachycardia, diaphoresis, salivation and incontinence
Lab investigations for neuroleptic malignant syndrome
Creatine kinase raised
Leucocytosis
Deranged LFT
Treatment for neuroleptic malignant syndrome
Withdraw antipsychotic medication
Monitor temperature, blood pressure and pulse
Consider benzodiazepine for sedation
Rehydration
Dopamine agonist like Bromocriptine or dantrolene may be used
Always consult a psychiatrist before starting any antipsychotic medication in any patients who might have had NMS
What is acute dystonia
Reversible extrapyramidal side effects that occur after administration of antipsychotic medications
Muscle spasm occurring anywhere in the body-characterised by intermittent spasmodic or sustained involuntary contractions of muscles of face, neck, trunk, pelvis, extremities and larynx
Which drugs will likely cause acute dystonia
Which are least likely to cause it
High potency D2 receptor medications
Atypical less likely to cause
How to treat dystonia
Anticholinergic medic actions like procyclidine
What is catatonia
Retarded type: paucity of movement, including immobility, staring, mutism, rigidity, withdrawal and refusal to eat. Can also have bizarre features such as posturing, grimacing, negativism, wavy flexibility, echolalia
Excited type: severe psychomotor agitation, potentially leading to life-threatening complications such as hyperthermia, altered consciousness and autonomic dysfunction
Treatment of catatonia
Low dose Benzodiazepines
Electroconvulsive therapy occasionally required
What is lithium excreted by
Kidneys- important to check for blood levels as can have toxicity
What is clearance of lithium reduced in
Patients with renal impairment (older adults, dehydration) and sodium depletion
What medications can increase lithium levels
Diuretics (thiazides)
NSAIDs
ACEi
Early symptoms of lithium toxicity
Marker tremor Anorexia N&V Diarrhoea Dehydration and lethargy
Later symptoms of lithium toxicity
Restlessness Muscle fasciculations Myoclonic jerks Choreo-athetoid movements Marked hypertonicity This may progress to ataxia, dysarthria, increased lethargy, drowsiness, confusion, hypotension, arrhythmias, emerging seizures, stupor and coma
treatment of lithium
Adequate hydration and salt intake
Stop lithium
In severe toxiciy- forced diuresis or harm-dialysis
What is serotonin syndrom
Occurs in dose increase or initiation of serotonergic medication
Usually occurs when patient is switched from one antidepressant to another
When a combination of antidepressants is used
Symptoms of serotonin syndrome
-Psychiatric Restlessness Confusion Agitation -Autonomic Hyperthermia (could be related to prolong seizure activity, rigidity or muscular hyperactivity) GI upset Tachycardia Hypo or hypertension Mydriasis -Neuromuscular Myoclonus Rigidity Tremors Hyperreflexia Ataxia Convulsions
No clinical investigations to diagnose it
Treatment of serotonin syndrome
Stop meds Symptomatic treatment with rehydration Benzodiazepines for agitation Transfer to ED if severe GAstric lavage if overdose
Neuroleptic malignant syndrome vs serotonin syndrome
Neuroleptic-
- Caused by antipsychotics
- Slow onset (days-weeks)
- SLow pregression
- Severe muscle rigidity
- Braydkinesia
Serotonin
- Serotonergic medications
- Rapid onset
- Rapid progression
- Less severe muscle rigidity
- Hyperkinesia
