Psychiatric Emergencies

Question 1

what are the 4 psych emergencies

Answer 1

1. acute dystonia
2. catatonia
3. Neuroleptic malignant syndrome - NMS
4. Serotonin Syndrome - SS

Question 2

what are the 3 symptoms of acute dystonia

Answer 2

1. oculogyric crisis
2. tongue protrusion
3. torticollis

Question 3

what causes acute dystonia

Answer 3

Dopamine-receptor blockade disrupting dopaminergic-cholinergic balance in basal ganglia (substantia nigra) → excess cholinergic output.

Question 4

what drugs can cause acute dystonia

Answer 4

cimetidine, carbamazepine, diazepam, diphenhydramine, cocaine, ecstasy, sumatriptan

Question 5

what is acute dystonia

Answer 5

movement disorder characterised by slow sustained or intermittent muscle contractions causing abnormal, often repetitive, movements, postures, or both

Question 6

what is the normal presentation of a patient with acute dystonia

Answer 6

1. Young male recently on a rapid dose increase
2. Patient whose EPSE prophylaxis was missed, stopped or reduced

Question 7

what is the first line management of acute dystonia

Answer 7

Diphenhydramine (50 mg IV bolus, repeat PRN in 30 mins)

Benzatropine (2 mg IV bolus)

Question 8

what is catatonia

Answer 8

at least 3 DSM-5 symptoms

Question 9

what are the DSM-5 symptoms of catatonia (12 symptoms)

Answer 9

Catalepsy: Passive induction of postures held against gravity

Posturing: Spontaneous + active maintenance of posture
against gravity

Waxy flexibility: Slight + even resistance to repositioning

Stupor: No psychomotor activity or reactivity to environment

Agitation: Not influenced by external stimuli

Negativism: Opposing/not responding to external stimuli/instructions

Mutism: No or minimal verbal response (except if established aphasia)

Grimacing: Maintenance of odd facial expression

Mannerism: Odd caricature of ordinary actions

Stereotypies: Repetitive, frequent, non-goal directed movements

Echolalia: Repeating the words spoken by the examiner

Echopraxia: Mimicking of movements made by the examiner

Question 10

what chemical in the brain is responsible for catatonia

Answer 10

GABA

Question 11

what are some of the signs of catatonia

Answer 11

sitting or standing for hours
holding odd positions
fever, psychomotor agitation

Question 12

what causes catatonia

Answer 12

bipolar and schizophrenia
depression, OCD, PTSD, autism
infection (meningitis, encephalitis) and autoimmune conditions affecting the CNS
withdrawal of benzos
substance misuse or withdrawal - alcohol/cocaine

Question 13

what is the treatment for catatonia

Answer 13

lorazepam 1-2mg
ECT

Question 14

what is a key distinguishing feature between NMS and SS

Answer 14

NMS = lead pipe rigidity
SS = hyperreflexia & clonus

Question 15

what is the onset of SS

Answer 15

acute - hours

Question 16

what is the onset of NMS

Answer 16

gradual - days/weeks

Question 17

how does someone with SS present

Answer 17

tachycardia, HTN, hyperthermia, rigidity, diaphoresis

Question 18

how does NMS present

Answer 18

tachycardia, HTN, hyperthermia, rigidity, diaphoresis, delirium

Question 19

what neurological sign of SS

Answer 19

hyperreflexia

Question 20

what is the key neurological sign of NMS

Answer 20

hyporeflexia

Question 21

which syndrome has a raised CK

Answer 21

NMS (but SS can have a raised one too)

Question 22

what is the management of SS

Answer 22

stop serotonergic drugs
IV fluids
cooling
benzodiazepines
cyproheptadine

Question 23

what is the management of NMS

Answer 23

stop the antipsychotics
IV fluids
dantrolene/lorazepam - muscle relaxant
Bromocriptine/amantadine - dopamine agonist