Psychiatric Emergencies

Question 1

Managing the Aggressive Patient

Answer 1

Physical Restraints: monitor closely - position, respiration, aspiration

Medications: benzos, 1st and 2nd generation antipsychotics

Question 2

Benzodiazepines

Answer 2

Preferred to sedate agitated patients with cause unknown

Lorazepam, Midazolam (shorter 1/2 life)

Can cause respiratory depression - monitor closely

Can use with first generation antipsychotics

Question 3

First Generation Antipsychotics

Answer 3

Haloperidol, Droperidol (BBW)

Both cause QT prolongation - may cause dysrhythmias

Avoid with ETOH, benzo, or any other withdrawal

Avoid in pts w/ anticholinergic sx

Avoid w/ seizures, pregnancy, and lactating females

Question 4

Second Generation Antipsychotics

Answer 4

Olanzapine (Zyprexa), Risperidone (Risperdal)

Less sedation, fewer extrapyramidal side effects

Less studies use w/ benzos - first gen may a better if those are on board

Question 5

Drug Selection:

Severely violent, need immediate sedation

Agitation from drug intoxication

Undifferentiated agitation

Agitated pts w/ known psych disorder

Answer 5

Severely violent, need immediate sedation: First gen AP +/- benzo

Agitation from drug intoxication: Benzos

Undifferentiated agitation: benzo preferred

Agitated pts w/ known psych disorder: second gen AP

Question 6

Paradoxical Reactions

Answer 6

May occur in some patients

Medications have the opposite effect (make them more aggressive)

Switch to an agent from a different class

Question 7

Post-Restraint Medical Evaluation

Answer 7

Complete set of vitals

Thorough mental status and neuro exam

Rapid blood glucose determination

Rule out acute medical condition

Question 8

Acute AIDS Encephalopathy

Answer 8

Change in mental status w/ abnormal neuro exam

Have to determine the degree of immunosuppression to differentiate cause

CD4 >500 = benign/malignant brain tumor/mets

CD4 200-500 = HIV-associated, rarely focal lesions

CD4 <200 = opportunistic infection (CMV), AIDS associated tumors

Question 9

Cocaine Effects

Answer 9

Anxiety/irritability

Panic attacks

Suspicious/paranoia - delusions/hallucinations

Grandiosity or impaired judgement

Question 10

Cocaine Withdrawal Symptoms

Answer 10

Prominent psychological features

• Depression, anxity, fatigue
• Difficulty concentrating, cocaine cravings
• Increased sleep and appetite

Physical symptoms - usually minor

-Arthralgia’s, tremor, chills

Question 11

Cocaine Withdrawal Treatment

Answer 11

Supportive

No meds shown to help

Hospitalization for psychological symptoms

Question 12

Methamphetamine and Associated Psychiatric Symptoms

Answer 12

Paranoia, psychosis, delusions

Homicidal, suicidal

Mood disturbances

Anxiety, hallucinations

Question 13

Methamphetamine Complications

Answer 13

Hypovolemia

Metabolic acidosis

Hyperthermia

Rhabdomyalysis (CK to check)

Question 14

Methamphetamine Treatment

Answer 14

Control agitation w/ benzodiazepines or 2nd gen AP

Succinylcholine is CI; Also avoid BB w/ HTN

Try to avoid restraints

Control hyperthermia, HTN - nitroprusside

Question 15

Neuroleptic Malignant Syndrome (NMS)

Answer 15

Life-threatening neurologic emergency w/ neuroleptic agent use

-MC w/ first gen high potency agents, also antiemetic

Sx: AMS< muscular rigidity, hyperthermia, Autonomic instability, hyperreflexia

Usually develops within first 2 weeks therapy - high doses are a risk factor

Can be seen w/ withdrawn anti-parkinsonian medications

Question 16

Neuroleptic Malignant Syndrome (NMS) Treatment and Diagnosis

Answer 16

Only positive diagnostic test: CK >1000 IU/L

Stop causative agent

Also stop other potential psychotropic agents

If due to dopamine withdrawal - restart dopamine

Supportive

Question 17

Alcohol Withdrawal Seizures

Answer 17

Occur 12-48 hours after last drink

MC in patients with chronic alcoholism

Usually singular or over short period

Treat with benzodiazepines (1st) and phenobarbital

Question 18

Alcoholic Hallucinosis

Answer 18

12-24 hours after last drink; resolve w/in 24-48 hours

Usually visual; auditory and tactile can occur

No clouding of the sensorium

Vitals are normal

Supportive therapy

Question 19

Delirium Tremens (DTs)

Answer 19

Begins 48-95 hours after last drink; lasts 1-5 days

Hallucinations, disorientation, agitation, tachycardia, HTN, fever

Benzos, Thiamine

If high dose benzos don’t work, can add phenobarbital

Question 20

Catatonia

Answer 20

Immobility, stupor, mutism, muscular rigidity w/ waxy flexibility, posturing, staring

Behavioral syndrome with the inability to move normally despite the physical capacity to do so

Treatment: Lorazepam, ECT w/in 5 day sx onset, treat underlying cause (psych or medical disorder)

Question 21

Serotonin Syndrome

Answer 21

Increased serotonergic activity in CNS

Occurs over hours, resolved in 24 hours

AMS, autonomic hyperactivity, neuromuscular abnormalities

Hunter Criteria = serotonergic agent + one other criteria

Treatment: DC serotonergic agent, supportive, benzo for sedation, administer serotonin antagonists - cyprohepatdine