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Psychiatric Emergencies Flashcards

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
Define Psychosis
Disturbance in the perception of reality, evidenced by hallucinations, delusions, or thought disorganization
26
What disorders does psychosis occur?
``` 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 ```
27
Evaluation in Psychosis
``` Mini-mental Observation of patient in general Vitals PE Chem panel CBC Thyroid functions UA Drug screen ```
28
Adverse Effects of Cocaine Use
``` Anxiety Irritability Panic attacks Suspiciousness Paranoia Grandiosity Impaired judgement Delusions Hallucinations ```
29
Physical Symptoms of Cocaine Use
``` Tachycardia HTN Hyperthermic Diaphoretic Dilated pupils Hyper-reflexia Resting tremor ```
30
Withdrawal Symptoms of Cocaine
``` Depression Anxiety Fatigue Difficulty concentrating Craving cocaine Increased sleep Increased appetite Arthralgias Tremor Chills ```
31
Treatment of Withdrawal of Cocaine
Supportive Allow patient to sleep and eat as needed Hospitalization for psychological symptoms
32
When can a patient who is high on cocaine be discharged?
Must be cleared medically and by psych
33
Signs and Symptoms of Methamphetamine Overdose
``` Tachycardia HTN Hyperthermic Diaphoretic Dilated pupils Hyper-reflexia Resting tremor More mood disturbances ```
34
Psychiatric Symptoms with Methamphetamine Overdose
``` Paranoia Psychosis Delusions Homicidality Suicidality Mood disturbances Anxiety Hallucinations ```
35
Diagnosing Methamphetamine Overdose
Sympathomimetic toxidrome | Differentiate from cocaine and PCP
36
Complications of Methamphetamine Overdose
Hypovolemia Metabolic acidosis Hyperthermia Rhabdomyolysis
37
Labs to Draw in Methamphetamine Overdose
``` Electrolytes Serum lactate Creatinine kinase Aminotransferases Clotting times Renal function ABG ```
38
Treatment of Methamphetamine Overdose
Control agitation Control hyperthermia Fluid resuscitation HTN: nitroprusside or phentolamine
39
What medication is contraindicated in methamphetamine overdose treatment?
Succinylcholine
40
Methamphetamine Treatment Pitfalls
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
Signs and Symptoms of Neuroleptic Malignant Syndrome
``` Mental status change Muscular rigidity Hyperthermia BP lability Tachycardia or bradycardia Problems urinating Unstable vitals ```
42
When does neuroleptic malignant syndrome (NMS) occur?
Usually: first 2 weeks of therapy Any time Anti-parkinsonian meds withdrawn
43
Diagnostics of Neuroleptic Malignant Syndrome (NMS)
``` 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
Treatment of Neuroleptic Malignant Syndrome (NMS(
Stop causative agent Potential psychotropic agents should be stopped Restart dopamine if dopamine withdrawal
45
Treatment of Neuroleptic Malignant Syndrome (NMS) Preventing
``` 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
Steps of Alcohol Withdrawal
``` Minor Withdrawal symptoms Alcoholic hallucinosis Delirium tremens (DT) Ethanol poisoning ```
47
Goals of Treatment of Alcohol Withdrawal
Manage symptoms Prevent serious events Bridge patients to treatment for recovery
48
Withdrawal Seizures in Alcohol Withdrawal
12-48 hours after last drink Common in long history chronic alcoholism Singular or over short period
49
Treatment of Withdrawal Seizures
Benzodiazepines
50
Alcoholic Hallucinosis in Alcohol Withdrawal
``` Develop: 12-24 hours after last drink Resolve: 24-48 hours Usually visual No clouding of sensorium Vitals normal ```
51
Treatment of Alcoholic Hallucinosis
Supportive therapy
52
Delirium Tremens (DTs) in Alcohol Withdrawal
Begins: 48-95 hours after last drink Resolve: 1-5 days Mortality Rate: 5%
53
Signs and Symptoms of Delirium Tremens (DTs)
``` Hallucinations Disorientation Agitation Tachycardia HTN Fever Diaphoresis Fluid/electrolyte issues ```
54
Assessment and Management of Delirium Tremens
R/O alternative diagnosis Control symptoms: benzodiazepines, IV fluids, nutritional supplementation, thiamine* Close monitoring
55
What medication can you use in delirium tremens (DTs) if benzodiazepines are not working?
Phenobarbital
56
Why can you not give antipsychotics in delirium tremens (DTs)
Lower the seizure threshold
57
Treatment of Acute Ethanol Intoxication
IV Thiamine
58
Define Panic Attacks
Sudden onset of intense fear and by the abrupt development of specific somatic, cognitive and affective symptoms
59
What medical disorders do you need to rule out before diagnosing panic attacks?
``` Angina Arrhythmias COPD/asthma Temporal lobe epilepsy PE Hyperthyroidism Pheochromocytoma ```
60
Symptoms of Depression
``` Lethargy Anhedonia Wake up early Change in appetite Decreased libido Poor concentration Suicidal thinking ```
61
What always needs to be asked about with depression?
Suicidal, homicidal, and manic states
62
Evaluating for Suicidal Risk
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
Management of a Suicidal State
Reduce immediate risk Manage underlying factors Monitor and follow up
64
Presentation of Schizophrenic Disorders
Psychosis and deterioration in functional capacity
65
Examination of Schizophrenic Disorders
H&P Homicidal/suicidal risk Mental health exam Ask about hallucinations and delusions
66
Diagnosis of Schizophrenic Disorders
``` CBC CMP MRI/CT of head Heavy metal screen EEG Hep C HIV ```
67
Treatment of Schizophrenic Disorders
Injectable antipsychotics | Orally disintegrating tablets for cooperative patients
68
What do patients with a paranoid state need to be cleared from for discharge?
Medically for delirium | Other cognitive dysfunctional medical conditions
69
Signs and Symptoms of Catatonia
``` Immobility Stupor Mutism or incomprehensible phrases Muscular rigidity with waxy flexibility Posturing Staring Negativism Automatic obedience ```
70
Etiology of Catatonia
``` Major depression Manic episode Epilepsy Encephalitis Antipsychotics Benzodiazepine withdrawal Hepatic encephalopathy SLE Wilson's disease Lyme disease ```
71
Treatment of Catatonia
Treat underlying cause Supportive Lorazepam ECT
72
Signs and Symptoms of a Manic State
Risky behavior Lots of energy No/not much sleep Gradiosity
73
Management of a Manic State
``` Discontinue antidepressants Evaluate and treat substance abuse Lithium carbonate Anticonvulsants Antipsychotics Benzodiazepines ECT ```
74
Define Conversion Disorder
Neurologic symptoms that are inconsistent with a neurologic disease, but cause distress and/or impairment
75
Define Somatization
Syndrome of nonspecific symptoms that are distressing
76
What can symptoms of somatization be caused or exacerbated by?
Anxiety Depression Interpersonal conflict
77
Management of Somatization
``` Thorough H&P Judicious testing Possible malingering NO OPIOIDS Need psych referral ```
78
Symptoms of Serotonin Syndrome
``` Mental status change Autonomic hyperactivity Neuromuscular abnormalities (hyper-reflexia) ```
79
Hunter Criteria for Diagnosing Serotonin Syndrome
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
Treatment of Serotonin Syndrome
``` Discontinuation of serotonergic agent Oxygen IV hydration Continuous monitoring Sedation with benzodiazepines Control hyperthermia Administer of serotonin antagonists ```
81
Medications with Serotonergic Activity
``` 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
Criteria for Involuntary Psychiatric Admission
Presence of mental illness Vary from state to state +/- danger to self or others Inability to adequately care for self
83
Types of Involuntary Hospitalization
Emergency detention Observational commitment Extended commitment
84
Duration of Emergency Detention
1-3 days
85
Who can initiate an observational commitment?
Physicians or hospital personnel | Sometimes court approval
86
How does an extended commitment occur?
Formal application 2 physicians Requires a hearing
87
Proper Use of Restraints
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
Define Duty to Warn
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
When are benzodiazepines used in the ER?
Treatment of ETOH or sedative withdrawal Acute agitation Acute mania or agitate psychosis Control drug-induced hyper excitable states
90
SE of Benzodiazepines
``` Sedation Lethargy Respiratory depression Impaired psychomotor skills and judgement Cognitive dysfunction Delirium Ataxia Exacerbation of COPD, sleep apnea Cardiovascular instability Death ```
91
Acute Intoxication or Overdose of Benzodiazepines
Slurred speech Incoordination Unsteady gait Impaired attention or memory
92
Severe Benzodiazepine Overdose or in Combination with Other CNS Drugs
Stupor | Coma
93
What does long term use of antipsychotics have a high risk of?
Parkinsonian EPS Rigidity Bradykinesia Tremor
94
SE of 1st Generation Antipsychotic Medications
``` Galactorrhea Amenorrhea NMS Prolonged QT interval Sudden death ```
95
2nd Generation Antipsychotics Treat What Conditions
Schizophrenia Acute bipolar mania Acute agitation
96
Primary SE of 2nd Generation Antipsychotic Medications
Sedation Hypotension NMS Sudden death

Emergency Medicine (17 decks)

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