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Emergency Medicine > Psychiatric Emergencies > Flashcards

Psychiatric Emergencies Flashcards

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1
Q

Factors Associated with Violence

A

Male
History of violence
Drug or ETOH abuse

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2
Q

Signs of Impending Violence

A 
Provocative behavior
Angry demeanor
Loud, aggressive speech
Tense posturing
Frequently changing body position
Aggressive acts
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3
Q

Management of Potentially Violent Patients

A

Remove patient from contact with other patients

Expedite evaluation

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4
Q

Verbal Techniques for Angry Patients

A 
Address violence directly
Set limits
Do not be provocative
Be honest and straightforward
Calm and soothing tone of voice
Concise, simple language
Offer choices and optimism
Stand at least 1 arms length away
Identify feelings and desires
Take all threats seriously
Protect yourself
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5
Q

Indications for Physical Restraints

A

Imminent harm to others
Imminent harm to self
Significant disruption of important treatment or damage to environment
Continuation of effective, ongoing behavior treatment plan

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6
Q

Use of Physical Restraints

A 
Follow protocol
5 person restraint team
1 must be female
Monitor closely: position changes, respirations, avoid aspiration
DOCUMENT
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7
Q

3 Classes of Medications for Chemical Restraints

A

Benzodiazepines
1st generation antipsychotics
2nd generation antipsychotics

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8
Q

What class of medication is preferred when sedating patients with an unknown cause of agitation?

A

Benzodiazepines

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9
Q

Benzodiazepines Used in Chemical Restraint

A

Lorazepam

Midazolam

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10
Q

SE of Benzodiazepines

A

Respiratory depression

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11
Q

1st Generation Antipsychotic Agents

A

Haloperidol

Droperidol

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12
Q

SE of First Generation Antipsychotics

A

QT prolongation

Potential for causing dysrhythmias

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13
Q

When should 1st generation antipsychotics be avoided?

A 
Alcohol withdrawal
Benzodiazepine withdrawal
Other withdrawal symptoms
Anticholinergic toxicity
Patients with seizures
Pregnant/lactating females
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14
Q

Second Generation Antipsychotic Agents

A

Olanzapine (Zyprexa)
Rispiradone (Risperdal)
Ziprasidone (Geodon)

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15
Q

Benefits of 2nd Generation Antipsychotics

A

Less sedation

Fewer extrapyramidal SE

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16
Q

Downside of 2nd Generation Antipsychotics

A

Less experience

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17
Q

When should a 1st or 2nd generation antipsychotic be used in violent patients?

A

Agitated patients with a known psychiatric disorder

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18
Q

Legal Considerations for Restraining Patients

A

Coworker agree with assessment and treatment
Reasons for restraint clearly documented
Duty to Warn

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19
Q

Post-Restraint Medical Evaluation

A

Complete set of vitals
Mental status and neuro exams
Blood glucose
R/O acute medical condition

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20
Q

Presentation of AIDS Encephalopathy

A

Change in mental status

Abnormal neurologic exam

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21
Q

Most Common Etiologies of AIDS Encephalopathy

A 
Toxoplasmosis encephalitis
Primary CNS lymphoma
Progressive multifocal leukoencephalopathy
HIV encephalopathy
CMV encephalopathy
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22
Q

CD4 Count 500+ with CNS Lesions

A

Benign and malignant brain tumors

Metastases

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23
Q

CD4 Count 200-500 with CNS Lesions

A

HIV associated cognitive and motor disorders

Usually not focal lesions

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24
Q

CD4 Count Less than 200 with CNS Lesions

A

Opportunistic infections

AIDS-associated tumors

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25
Q

Define Psychosis

A

Disturbance in the perception of reality, evidenced by hallucinations, delusions, or thought disorganization

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26
Q

What disorders does psychosis occur?

A 
Schizophrenia
Bipolar mania
Major depression with psychotic features
Schizoaffective disorder
Alzheimer's disease
Delirium
Substance induced psychotic disorder
Delusional disorder
Psychosis secondary to a medical condition
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27
Q

Evaluation in Psychosis

A 
Mini-mental
Observation of patient in general
Vitals
PE
Chem panel
CBC
Thyroid functions
UA
Drug screen
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28
Q

Adverse Effects of Cocaine Use

A 
Anxiety
Irritability
Panic attacks
Suspiciousness
Paranoia
Grandiosity
Impaired judgement
Delusions
Hallucinations
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29
Q

Physical Symptoms of Cocaine Use

A 
Tachycardia
HTN
Hyperthermic
Diaphoretic
Dilated pupils
Hyper-reflexia
Resting tremor
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30
Q

Withdrawal Symptoms of Cocaine

A 
Depression
Anxiety 
Fatigue
Difficulty concentrating
Craving cocaine
Increased sleep
Increased appetite
Arthralgias
Tremor
Chills
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31
Q

Treatment of Withdrawal of Cocaine

A

Supportive
Allow patient to sleep and eat as needed
Hospitalization for psychological symptoms

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32
Q

When can a patient who is high on cocaine be discharged?

A

Must be cleared medically and by psych

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33
Q

Signs and Symptoms of Methamphetamine Overdose

A 
Tachycardia
HTN
Hyperthermic
Diaphoretic
Dilated pupils
Hyper-reflexia
Resting tremor
More mood disturbances
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34
Q

Psychiatric Symptoms with Methamphetamine Overdose

A 
Paranoia
Psychosis
Delusions
Homicidality
Suicidality
Mood disturbances
Anxiety
Hallucinations
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35
Q

Diagnosing Methamphetamine Overdose

A

Sympathomimetic toxidrome

Differentiate from cocaine and PCP

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36
Q

Complications of Methamphetamine Overdose

A

Hypovolemia
Metabolic acidosis
Hyperthermia
Rhabdomyolysis

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37
Q

Labs to Draw in Methamphetamine Overdose

A 
Electrolytes
Serum lactate
Creatinine kinase
Aminotransferases
Clotting times
Renal function
ABG
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38
Q

Treatment of Methamphetamine Overdose

A

Control agitation
Control hyperthermia
Fluid resuscitation
HTN: nitroprusside or phentolamine

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39
Q

What medication is contraindicated in methamphetamine overdose treatment?

A

Succinylcholine

40
Q

Methamphetamine Treatment Pitfalls

A

Failure to respect agitation and potential for violence
Failure to treat hyperthermia
Failure to recognize rhabdomyolysis
Failure to consider associated illness and trauma
Failure to note risk of contamination of drug ingestion

41
Q

Signs and Symptoms of Neuroleptic Malignant Syndrome

A 
Mental status change
Muscular rigidity
Hyperthermia
BP lability
Tachycardia or bradycardia
Problems urinating
Unstable vitals
42
Q

When does neuroleptic malignant syndrome (NMS) occur?

A

Usually: first 2 weeks of therapy
Any time
Anti-parkinsonian meds withdrawn

43
Q

Diagnostics of Neuroleptic Malignant Syndrome (NMS)

A 
Brain MRI/CT: R/O mass lesion
LP: R/O infection
CBC
Chem panel
Electroenphalography: R/O seizures
Toxicology screen
Creatinine kinase elevation: R/O rhabdomyolysis
44
Q

Treatment of Neuroleptic Malignant Syndrome (NMS(

A

Stop causative agent
Potential psychotropic agents should be stopped
Restart dopamine if dopamine withdrawal

45
Q

Treatment of Neuroleptic Malignant Syndrome (NMS) Preventing

A 
Dehydration
Electrolyte imbalance
Acute renal failure
Cardiac arrhythmias or cardiac arrest
MI
Cardiomyopathy
Respiratory failure
Aspiration pneumonia
PE
DVT
DIC
Seizures
Hepatic failure
Sepsis
46
Q

Steps of Alcohol Withdrawal

A 
Minor
Withdrawal symptoms
Alcoholic hallucinosis
Delirium tremens (DT)
Ethanol poisoning
47
Q

Goals of Treatment of Alcohol Withdrawal

A

Manage symptoms
Prevent serious events
Bridge patients to treatment for recovery

48
Q

Withdrawal Seizures in Alcohol Withdrawal

A

12-48 hours after last drink
Common in long history chronic alcoholism
Singular or over short period

49
Q

Treatment of Withdrawal Seizures

A

Benzodiazepines

50
Q

Alcoholic Hallucinosis in Alcohol Withdrawal

A 
Develop: 12-24 hours after last drink
Resolve: 24-48 hours
Usually visual
No clouding of sensorium
Vitals normal
51
Q

Treatment of Alcoholic Hallucinosis

A

Supportive therapy

52
Q

Delirium Tremens (DTs) in Alcohol Withdrawal

A

Begins: 48-95 hours after last drink
Resolve: 1-5 days
Mortality Rate: 5%

53
Q

Signs and Symptoms of Delirium Tremens (DTs)

A 
Hallucinations
Disorientation
Agitation
Tachycardia
HTN
Fever
Diaphoresis
Fluid/electrolyte issues
54
Q

Assessment and Management of Delirium Tremens

A

R/O alternative diagnosis
Control symptoms: benzodiazepines, IV fluids, nutritional supplementation, thiamine*
Close monitoring

55
Q

What medication can you use in delirium tremens (DTs) if benzodiazepines are not working?

A

Phenobarbital

56
Q

Why can you not give antipsychotics in delirium tremens (DTs)

A

Lower the seizure threshold

57
Q

Treatment of Acute Ethanol Intoxication

A

IV Thiamine

58
Q

Define Panic Attacks

A

Sudden onset of intense fear and by the abrupt development of specific somatic, cognitive and affective symptoms

59
Q

What medical disorders do you need to rule out before diagnosing panic attacks?

A 
Angina
Arrhythmias
COPD/asthma
Temporal lobe epilepsy
PE
Hyperthyroidism
Pheochromocytoma
60
Q

Symptoms of Depression

A 
Lethargy
Anhedonia
Wake up early
Change in appetite
Decreased libido
Poor concentration
Suicidal thinking
61
Q

What always needs to be asked about with depression?

A

Suicidal, homicidal, and manic states

62
Q

Evaluating for Suicidal Risk

A

Presence of ideation, intent, or plan
Access to means and lethality of those means
Presence of psychotic symptoms, command hallucinations, or severe anxiety
Presence of alcohol or substance use
History and seriousness of previous attempts
Family history of recent exposure to suicide
Degree of hopelessness and impulsivity

63
Q

Management of a Suicidal State

A

Reduce immediate risk
Manage underlying factors
Monitor and follow up

64
Q

Presentation of Schizophrenic Disorders

A

Psychosis and deterioration in functional capacity

65
Q

Examination of Schizophrenic Disorders

A

H&P
Homicidal/suicidal risk
Mental health exam
Ask about hallucinations and delusions

66
Q

Diagnosis of Schizophrenic Disorders

A 
CBC
CMP
MRI/CT of head
Heavy metal screen
EEG
Hep C
HIV
67
Q

Treatment of Schizophrenic Disorders

A

Injectable antipsychotics

Orally disintegrating tablets for cooperative patients

68
Q

What do patients with a paranoid state need to be cleared from for discharge?

A

Medically for delirium

Other cognitive dysfunctional medical conditions

69
Q

Signs and Symptoms of Catatonia

A 
Immobility
Stupor
Mutism or incomprehensible phrases
Muscular rigidity with waxy flexibility
Posturing
Staring
Negativism
Automatic obedience
70
Q

Etiology of Catatonia

A 
Major depression
Manic episode
Epilepsy
Encephalitis
Antipsychotics
Benzodiazepine withdrawal
Hepatic encephalopathy
SLE
Wilson's disease
Lyme disease
71
Q

Treatment of Catatonia

A

Treat underlying cause
Supportive
Lorazepam
ECT

72
Q

Signs and Symptoms of a Manic State

A

Risky behavior
Lots of energy
No/not much sleep
Gradiosity

73
Q

Management of a Manic State

A 
Discontinue antidepressants
Evaluate and treat substance abuse
Lithium carbonate
Anticonvulsants
Antipsychotics
Benzodiazepines
ECT
74
Q

Define Conversion Disorder

A

Neurologic symptoms that are inconsistent with a neurologic disease, but cause distress and/or impairment

75
Q

Define Somatization

A

Syndrome of nonspecific symptoms that are distressing

76
Q

What can symptoms of somatization be caused or exacerbated by?

A

Anxiety
Depression
Interpersonal conflict

77
Q

Management of Somatization

A 
Thorough H&P
Judicious testing
Possible malingering
NO OPIOIDS
Need psych referral
78
Q

Symptoms of Serotonin Syndrome

A 
Mental status change
Autonomic hyperactivity
Neuromuscular abnormalities (hyper-reflexia)
79
Q

Hunter Criteria for Diagnosing Serotonin Syndrome

A

Taking a serotonergic agent PLUS one of the following:
Spontaneous clonus
Inducible clonus + agitation or diaphoresis
Ocular clonus + agitation ro diaphoresis
Tremor + hyper-reflexia
Hypertonia + temp above 38C + ocular clonus or inducible clonus

80
Q

Treatment of Serotonin Syndrome

A 
Discontinuation of serotonergic agent
Oxygen
IV hydration
Continuous monitoring
Sedation with benzodiazepines
Control hyperthermia
Administer of serotonin antagonists
81
Q

Medications with Serotonergic Activity

A 
Codeine
Fentanyl
Meperidine
Tramadol
Linezolid
SSRIs
SNRIs
TCAs
MAOIs
Bupropion
Trazodone
Dopamine agonists
Triptans
St. Johns wort
Panax ginseng
Tryptophan
Drugs of abuse
Buspirone
Dextromethorphan
Lithium
82
Q

Criteria for Involuntary Psychiatric Admission

A

Presence of mental illness
Vary from state to state
+/- danger to self or others
Inability to adequately care for self

83
Q

Types of Involuntary Hospitalization

A

Emergency detention
Observational commitment
Extended commitment

84
Q

Duration of Emergency Detention

A

1-3 days

85
Q

Who can initiate an observational commitment?

A

Physicians or hospital personnel

Sometimes court approval

86
Q

How does an extended commitment occur?

A

Formal application
2 physicians
Requires a hearing

87
Q

Proper Use of Restraints

A

Prevention of injury to self or others
Prevention of serious physical damage to unit or disruption of ER
Control of patient so an evaluation can be done

88
Q

Define Duty to Warn

A

If patient divulges that he/she is going to harm a specific person, it is our duty to warn that person of the patient’s intentions

89
Q

When are benzodiazepines used in the ER?

A

Treatment of ETOH or sedative withdrawal
Acute agitation
Acute mania or agitate psychosis
Control drug-induced hyper excitable states

90
Q

SE of Benzodiazepines

A 
Sedation
Lethargy
Respiratory depression
Impaired psychomotor skills and judgement
Cognitive dysfunction
Delirium
Ataxia
Exacerbation of COPD, sleep apnea
Cardiovascular instability
Death
91
Q

Acute Intoxication or Overdose of Benzodiazepines

A

Slurred speech
Incoordination
Unsteady gait
Impaired attention or memory

92
Q

Severe Benzodiazepine Overdose or in Combination with Other CNS Drugs

A

Stupor

Coma

93
Q

What does long term use of antipsychotics have a high risk of?

A

Parkinsonian EPS
Rigidity
Bradykinesia
Tremor

94
Q

SE of 1st Generation Antipsychotic Medications

A 
Galactorrhea
Amenorrhea
NMS
Prolonged QT interval
Sudden death
95
Q

2nd Generation Antipsychotics Treat What Conditions

A

Schizophrenia
Acute bipolar mania
Acute agitation

96
Q

Primary SE of 2nd Generation Antipsychotic Medications

A

Sedation
Hypotension
NMS
Sudden death

Emergency Medicine (17 decks)

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