psychiatric emergencies

Question 1

Major psychiatric emergencies

Answer 1

Suicidal patients

Agitated and violent patients

Question 2

Other psychiatric emergencies

Answer 2

Grief reaction
Rape
Disaster
Panic attacks

Question 3

Medical emergencies in psychiatry

Answer 3

Delirium
Neuroleptic Malignant Syndrome
Serotonin syndrome
Overdose of common psychiatric medications
Overdose and withdraw from addicting substance

Question 4

Clinical features of delirium

Answer 4

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

Question 5

Types of delirium

Answer 5

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Hypoactive delirium: a subtype of delirium characterised by people who become withdrawn, quiet and sleepy.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

Question 6

Assessment

Answer 6

History
Physical exam and investigations
Risk assessment
BAseline cognitive examination: (AMT, MoCA, MMSE)

Question 7

Investigations for delirium

Answer 7

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

Question 8

Causes for delirium

Answer 8

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

Question 9

Warning signs for violent behaviours

Answer 9

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)

Question 10

Medications used for rapid tranquillisation

Answer 10

Benzodiazepines (lorazepam)
Antipsychotics
Combination of the above
PRomethazine

Question 11

Benzodiazepines in order of increasing time it taks

es ro act

Answer 11

Lorazepam
Midazolam
Diazepam

Question 12

What antipsychotics used to reduce agitation

Answer 12

Haloperidol

Olanzapine

Question 13

Symptoms of neuroleptic malignant syndrome

Answer 13

Fever, diaphoresis (sweating), rigidity, confusion and fluctuating consciousness

Autonomic instability can present as fluctuating BP, tachycardia, diaphoresis, salivation and incontinence

Question 14

Lab investigations for neuroleptic malignant syndrome

Answer 14

Creatine kinase raised
Leucocytosis
Deranged LFT

Question 15

Treatment for neuroleptic malignant syndrome

Answer 15

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

Question 16

What is acute dystonia

Answer 16

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

Question 17

Which drugs will likely cause acute dystonia

Which are least likely to cause it

Answer 17

High potency D2 receptor medications

Atypical less likely to cause

Question 18

How to treat dystonia

Answer 18

Anticholinergic medic actions like procyclidine

Question 19

What is catatonia

Answer 19

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

Question 20

Treatment of catatonia

Answer 20

Low dose Benzodiazepines

Electroconvulsive therapy occasionally required

Question 21

What is lithium excreted by

Answer 21

Kidneys- important to check for blood levels as can have toxicity

Question 22

What is clearance of lithium reduced in

Answer 22

Patients with renal impairment (older adults, dehydration) and sodium depletion

Question 23

What medications can increase lithium levels

Answer 23

Diuretics (thiazides)
NSAIDs
ACEi

Question 24

Early symptoms of lithium toxicity

Answer 24

Marker tremor
Anorexia 
N&V
Diarrhoea
Dehydration and lethargy

Question 25

Later symptoms of lithium toxicity

Answer 25

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

Question 26

treatment of lithium

Answer 26

Adequate hydration and salt intake
Stop lithium
In severe toxiciy- forced diuresis or harm-dialysis

Question 27

What is serotonin syndrom

Answer 27

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

Question 28

Symptoms of serotonin syndrome

Answer 28

-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

Question 29

Treatment of serotonin syndrome

Answer 29

Stop meds 
Symptomatic treatment with rehydration 
Benzodiazepines for agitation 
Transfer to ED if severe 
GAstric lavage if overdose

Question 30

Neuroleptic malignant syndrome vs serotonin syndrome

Answer 30

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