Psychiatric Emergencies Flashcards
Factors Associated with Violence
Male
History of violence
Drug or ETOH abuse
Signs of Impending Violence
Provocative behavior Angry demeanor Loud, aggressive speech Tense posturing Frequently changing body position Aggressive acts
Management of Potentially Violent Patients
Remove patient from contact with other patients
Expedite evaluation
Verbal Techniques for Angry Patients
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
Indications for Physical Restraints
Imminent harm to others
Imminent harm to self
Significant disruption of important treatment or damage to environment
Continuation of effective, ongoing behavior treatment plan
Use of Physical Restraints
Follow protocol 5 person restraint team 1 must be female Monitor closely: position changes, respirations, avoid aspiration DOCUMENT
3 Classes of Medications for Chemical Restraints
Benzodiazepines
1st generation antipsychotics
2nd generation antipsychotics
What class of medication is preferred when sedating patients with an unknown cause of agitation?
Benzodiazepines
Benzodiazepines Used in Chemical Restraint
Lorazepam
Midazolam
SE of Benzodiazepines
Respiratory depression
1st Generation Antipsychotic Agents
Haloperidol
Droperidol
SE of First Generation Antipsychotics
QT prolongation
Potential for causing dysrhythmias
When should 1st generation antipsychotics be avoided?
Alcohol withdrawal Benzodiazepine withdrawal Other withdrawal symptoms Anticholinergic toxicity Patients with seizures Pregnant/lactating females
Second Generation Antipsychotic Agents
Olanzapine (Zyprexa)
Rispiradone (Risperdal)
Ziprasidone (Geodon)
Benefits of 2nd Generation Antipsychotics
Less sedation
Fewer extrapyramidal SE
Downside of 2nd Generation Antipsychotics
Less experience
When should a 1st or 2nd generation antipsychotic be used in violent patients?
Agitated patients with a known psychiatric disorder
Legal Considerations for Restraining Patients
Coworker agree with assessment and treatment
Reasons for restraint clearly documented
Duty to Warn
Post-Restraint Medical Evaluation
Complete set of vitals
Mental status and neuro exams
Blood glucose
R/O acute medical condition
Presentation of AIDS Encephalopathy
Change in mental status
Abnormal neurologic exam
Most Common Etiologies of AIDS Encephalopathy
Toxoplasmosis encephalitis Primary CNS lymphoma Progressive multifocal leukoencephalopathy HIV encephalopathy CMV encephalopathy
CD4 Count 500+ with CNS Lesions
Benign and malignant brain tumors
Metastases
CD4 Count 200-500 with CNS Lesions
HIV associated cognitive and motor disorders
Usually not focal lesions
CD4 Count Less than 200 with CNS Lesions
Opportunistic infections
AIDS-associated tumors
Define Psychosis
Disturbance in the perception of reality, evidenced by hallucinations, delusions, or thought disorganization
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
Evaluation in Psychosis
Mini-mental Observation of patient in general Vitals PE Chem panel CBC Thyroid functions UA Drug screen
Adverse Effects of Cocaine Use
Anxiety Irritability Panic attacks Suspiciousness Paranoia Grandiosity Impaired judgement Delusions Hallucinations
Physical Symptoms of Cocaine Use
Tachycardia HTN Hyperthermic Diaphoretic Dilated pupils Hyper-reflexia Resting tremor
Withdrawal Symptoms of Cocaine
Depression Anxiety Fatigue Difficulty concentrating Craving cocaine Increased sleep Increased appetite Arthralgias Tremor Chills
Treatment of Withdrawal of Cocaine
Supportive
Allow patient to sleep and eat as needed
Hospitalization for psychological symptoms
When can a patient who is high on cocaine be discharged?
Must be cleared medically and by psych
Signs and Symptoms of Methamphetamine Overdose
Tachycardia HTN Hyperthermic Diaphoretic Dilated pupils Hyper-reflexia Resting tremor More mood disturbances
Psychiatric Symptoms with Methamphetamine Overdose
Paranoia Psychosis Delusions Homicidality Suicidality Mood disturbances Anxiety Hallucinations
Diagnosing Methamphetamine Overdose
Sympathomimetic toxidrome
Differentiate from cocaine and PCP
Complications of Methamphetamine Overdose
Hypovolemia
Metabolic acidosis
Hyperthermia
Rhabdomyolysis
Labs to Draw in Methamphetamine Overdose
Electrolytes Serum lactate Creatinine kinase Aminotransferases Clotting times Renal function ABG
Treatment of Methamphetamine Overdose
Control agitation
Control hyperthermia
Fluid resuscitation
HTN: nitroprusside or phentolamine
What medication is contraindicated in methamphetamine overdose treatment?
Succinylcholine
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
Signs and Symptoms of Neuroleptic Malignant Syndrome
Mental status change Muscular rigidity Hyperthermia BP lability Tachycardia or bradycardia Problems urinating Unstable vitals
When does neuroleptic malignant syndrome (NMS) occur?
Usually: first 2 weeks of therapy
Any time
Anti-parkinsonian meds withdrawn
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
Treatment of Neuroleptic Malignant Syndrome (NMS(
Stop causative agent
Potential psychotropic agents should be stopped
Restart dopamine if dopamine withdrawal
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
Steps of Alcohol Withdrawal
Minor Withdrawal symptoms Alcoholic hallucinosis Delirium tremens (DT) Ethanol poisoning
Goals of Treatment of Alcohol Withdrawal
Manage symptoms
Prevent serious events
Bridge patients to treatment for recovery
Withdrawal Seizures in Alcohol Withdrawal
12-48 hours after last drink
Common in long history chronic alcoholism
Singular or over short period
Treatment of Withdrawal Seizures
Benzodiazepines
Alcoholic Hallucinosis in Alcohol Withdrawal
Develop: 12-24 hours after last drink Resolve: 24-48 hours Usually visual No clouding of sensorium Vitals normal
Treatment of Alcoholic Hallucinosis
Supportive therapy
Delirium Tremens (DTs) in Alcohol Withdrawal
Begins: 48-95 hours after last drink
Resolve: 1-5 days
Mortality Rate: 5%
Signs and Symptoms of Delirium Tremens (DTs)
Hallucinations Disorientation Agitation Tachycardia HTN Fever Diaphoresis Fluid/electrolyte issues
Assessment and Management of Delirium Tremens
R/O alternative diagnosis
Control symptoms: benzodiazepines, IV fluids, nutritional supplementation, thiamine*
Close monitoring
What medication can you use in delirium tremens (DTs) if benzodiazepines are not working?
Phenobarbital
Why can you not give antipsychotics in delirium tremens (DTs)
Lower the seizure threshold
Treatment of Acute Ethanol Intoxication
IV Thiamine
Define Panic Attacks
Sudden onset of intense fear and by the abrupt development of specific somatic, cognitive and affective symptoms
What medical disorders do you need to rule out before diagnosing panic attacks?
Angina Arrhythmias COPD/asthma Temporal lobe epilepsy PE Hyperthyroidism Pheochromocytoma
Symptoms of Depression
Lethargy Anhedonia Wake up early Change in appetite Decreased libido Poor concentration Suicidal thinking
What always needs to be asked about with depression?
Suicidal, homicidal, and manic states
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
Management of a Suicidal State
Reduce immediate risk
Manage underlying factors
Monitor and follow up
Presentation of Schizophrenic Disorders
Psychosis and deterioration in functional capacity
Examination of Schizophrenic Disorders
H&P
Homicidal/suicidal risk
Mental health exam
Ask about hallucinations and delusions
Diagnosis of Schizophrenic Disorders
CBC CMP MRI/CT of head Heavy metal screen EEG Hep C HIV
Treatment of Schizophrenic Disorders
Injectable antipsychotics
Orally disintegrating tablets for cooperative patients
What do patients with a paranoid state need to be cleared from for discharge?
Medically for delirium
Other cognitive dysfunctional medical conditions
Signs and Symptoms of Catatonia
Immobility Stupor Mutism or incomprehensible phrases Muscular rigidity with waxy flexibility Posturing Staring Negativism Automatic obedience
Etiology of Catatonia
Major depression Manic episode Epilepsy Encephalitis Antipsychotics Benzodiazepine withdrawal Hepatic encephalopathy SLE Wilson's disease Lyme disease
Treatment of Catatonia
Treat underlying cause
Supportive
Lorazepam
ECT
Signs and Symptoms of a Manic State
Risky behavior
Lots of energy
No/not much sleep
Gradiosity
Management of a Manic State
Discontinue antidepressants Evaluate and treat substance abuse Lithium carbonate Anticonvulsants Antipsychotics Benzodiazepines ECT
Define Conversion Disorder
Neurologic symptoms that are inconsistent with a neurologic disease, but cause distress and/or impairment
Define Somatization
Syndrome of nonspecific symptoms that are distressing
What can symptoms of somatization be caused or exacerbated by?
Anxiety
Depression
Interpersonal conflict
Management of Somatization
Thorough H&P Judicious testing Possible malingering NO OPIOIDS Need psych referral
Symptoms of Serotonin Syndrome
Mental status change Autonomic hyperactivity Neuromuscular abnormalities (hyper-reflexia)
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
Treatment of Serotonin Syndrome
Discontinuation of serotonergic agent Oxygen IV hydration Continuous monitoring Sedation with benzodiazepines Control hyperthermia Administer of serotonin antagonists
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
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
Types of Involuntary Hospitalization
Emergency detention
Observational commitment
Extended commitment
Duration of Emergency Detention
1-3 days
Who can initiate an observational commitment?
Physicians or hospital personnel
Sometimes court approval
How does an extended commitment occur?
Formal application
2 physicians
Requires a hearing
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
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
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
SE of Benzodiazepines
Sedation Lethargy Respiratory depression Impaired psychomotor skills and judgement Cognitive dysfunction Delirium Ataxia Exacerbation of COPD, sleep apnea Cardiovascular instability Death
Acute Intoxication or Overdose of Benzodiazepines
Slurred speech
Incoordination
Unsteady gait
Impaired attention or memory
Severe Benzodiazepine Overdose or in Combination with Other CNS Drugs
Stupor
Coma
What does long term use of antipsychotics have a high risk of?
Parkinsonian EPS
Rigidity
Bradykinesia
Tremor
SE of 1st Generation Antipsychotic Medications
Galactorrhea Amenorrhea NMS Prolonged QT interval Sudden death
2nd Generation Antipsychotics Treat What Conditions
Schizophrenia
Acute bipolar mania
Acute agitation
Primary SE of 2nd Generation Antipsychotic Medications
Sedation
Hypotension
NMS
Sudden death
