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Psychiatry > Psychiatric Emergencies > Flashcards

Psychiatric Emergencies Flashcards

1
Q

List the symptoms of toxicity with lithium (7)

DAN Can’t Count his Crazy Drugs

A

Diarrhoea

Coarse tremor
Nystagmus

Dysarthria
Ataxia
Confusion
Convulsions

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2
Q

What factors may lead to lithium toxicity

A

Low sodium diets
Dehydration (advise to maintain hydrated)
Drug interactions
Some physicals e.g. Addison’s

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3
Q

How is serious lithium toxicity (>2.5) managed?

A

Emergency Tx inc. haemodialysis / forced diuresis

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4
Q

What are some examples of psychiatric emergencies (5)

What are some cases of medical emergencies in psychiatry (5)

A 
Panic attack
Rape
Grief reaction
Suicidal
Agitated/violent pts
NMS
Serotonin syndrome
Delirium
OD of medication
OD/withdrawal of addictive substance
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5
Q

What is the point prevalence of delirium in hospital?
What % elderly pts admitted/during hosp stay have delirium?
What psych condition is delirium commonly superimposed with?

A

10-30% point prevalence delirium in hosp

10-15% elderly pts admitted
10-40% elderly pts develop during hosp stay

2/3rd delirium is superimposed on dementia

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6
Q

What are the ICD-10 criteria for delirium (4+4+4)

A

Altered consciousness
Disorientation (time/place/person)
Attention deficits
Memory deficits (impaired immed recall / intact remote)

≥ 1 of:
Variable activity levels
Increased reaction time
Altered speech
Enhanced startle reaction
\+ ≥ 1 of:
Insomnia
Reversed sleep-wake cycle
Daytime drowsiness
Nocturnal worsening
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7
Q

What Ix can be done into delirium (6 categories)

A

Infection: urinalysis / cultures / FBC / CRP / CXR
Iatrogenic: review meds
Endocrine/metabolic: U+Es / LFTs / TFTs / Gluc
Neuro: CT/MRI
Cardiac: ECG
Hypoxia: O2 sats

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8
Q

What are the possible causes of delirium

I WATCH DEATH

A

Infection: HIV/Sepsis/Pneumonia

Withdrawal: alc / sedatives
Acute metabolic: acid/alk / elec abns / hep/renal failure
Trauma
CNS pathology: haemorrhage / abscess / inf / tumour
Hypoxia

Deficiencies: thiamine / niacin / B12 / folate
Endocrine: hypo/hyper - adrenocorticism/glycaemia/PTH
Acute vascular: stroke / hypertensive / arrhythmia / shock
Toxins/drugs
Heavy metals: lead/manganese/Hg

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9
Q

Describe the management of delirium (5)

A

ID/Treat precipitating cause
Avoid sedation unless severely agitated

Consider psych referral

Provide calm environment + supportive measures

Review regularly

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10
Q

In delirium, in what cases may you consider a psych referral (6)

A 
Persistent delirium
H/o MH probs
Suspect dementia/depression
Aggressive
Controversial capacity
Considering MHA
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11
Q

What are the diff types of delirium (5)

A 
Persisient
Hyperactive
Hypoactive
Mixed
Delirium superimposed on dementia
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12
Q

What are the 3 basic principles of managing acute behavioural disturbance

What approach is 1st line?

A

Predict risk of agitation
Prevent behaviour escalating
Interventions to ensure safety to pt/staff

De-escalation is 1st line (works in most cases - physical/meds only when this fails)

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13
Q

Whats the diff b/wn delirium + acute behavioural disturbance

A

Acute behavioural disturbance is a manifestation of underlying illness:
Organic (e.g. infection)
Psychiatric (e.g. psychosis, non-psychotic e.g. anxiety, or illicit substance use)

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14
Q

What drugs can be used for sedation in acute behavioural disturbance? (3)

A

BZDs (lorazepam / midazolam)
Antipsychotics (haloperidol / olanzapine)
Promethazine

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15
Q

List some considerations when deciding to rapidly tranquillise/sedate a pt?

A

If poss before, ECG/ ensure CPR facilities
Where poss give orally
If IM maintain dignity / same gender
Pt will not be approp for MHA assessment after (drowsy)
After, do approp physical obs (HR/BP/Temp/O2)

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16
Q

Describe the management in Acute Dystonia

A

Procyclidine IM/IV (anticholinergic - for drug-induced parkinsonism)
OR
Benzotropine

+ Check for cyanosis / Give O2 / any medical transfer

17
Q

Describe the management of resp depression as a psych emergency

A

Give O2
Raise legs
If RR<10 + BZDs → flumenazil

18
Q

List some etiological RFs for NMS that would be elicited from the Hx (4)

+ some Treatment related factors (5)

A

Previous NMS
Known cerebral compromise
Organic brain damage
Alcoholism

IM therapy
Recent/rapid increase
Anticholinergic rapid reduction/withdrawal
High-potency antipsychotic e.g. halo
High dose antipsychotic
19
Q

What may be seen on MSE/Physical Ex in NMS?

A

Physical Ex: dehydration

MSE: agitation / over activity / catatonia

20
Q

What Ix can be done in NMS (3)

A

No blood test Dx but possibly:
Creatinine Kinase raised
Leucocytosis
Deranged LFTs

21
Q

How is NMS managed (5)

A

Withdraw antipsychotic
Monitor BP/HR/Temp
Rehydration

Consider BZD
Dopamine agonist

22
Q

What are the Sx/features of NMS (HMCTx2)

A

Hyperthermia (+sweating/salivation)
Hypo/hypertension

Muscle rigidity
Metabolic acidosis

Confusion
Consciousness changing
(Creatinine Kinase raised)

Tachycardia
Tremor

23
Q

How does NMS occur?

A

Dopamine blockage → sympathetic hyperactivity

24
Q

How does Acute dystonia occur?

What is it characterised by? (definition/features)

A

= nigrostriatal D2R blockade → XS striatal cholinergic output

Intermittent spasmodic/sustained involuntary contractions of any muscle in body (face/neck/larynx/body) as an immediate/delayed reaction after antipsychotic admin (more common in typicals)

25
Q 
What is the prevalence of Acute Dystonia?
What factors (3) may increase risk?
A

10%

Neuroleptic naive
High potency e.g. halo
Young men (rare in elderly)

26
Q

Where does Acute Dystonia usually occur? (4)

A

Neck (torticollis)
Jaw
Tongue
Oculogyric crisis

27
Q

What 2 factors may reduce lithium excretion?

What 3 drugs can increase lithium serum levels?

A

Renal impairment + Na depletion

Diuretics (esp thiazides)
NSAIDs
ACEis

28
Q

What are the commonest causes in clinical practice for serotonin syndrome? (3)

A

Switching from one antidepressant → another
Combo of antidepressants
On antidepressants + other drugs (Triptans/St.Johns/Illegal)

29
Q

What are the possible symptoms of serotonin syndrome? (2 AC:5:6 MARCH T)

A

Psych: Agitation / Confusion

Autonomic: 
Hyperthermia (musc rigidity/hyperactivity)
Tachycardia, hyper/hypotension
GI upset
Mydriasis
Neuromuscular:
Myoclonus
Ataxia
Rigidity
Convulsions
Hyperreflexia
Tremor
30
Q

How may serotonin syndrome be managed? (5)

A

Stop immediately

Rehydrate + other symptomatic Tx
BZDs (for agitation)

Severe: transfer
OD: gastric lavage

Psychiatry (11 decks)

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