Psychiatric Emergencies

Question 1

Delirium Tremens (DTs)

Answer 1

• Typically within 2-4 days after cessation of EtOH but may occur later
• Delirium, agitation, fever, autonomic hyperactivity, auditory and visual hallucinations
• Treat aggressively with benzos and hydration

Question 2

Neuroleptic Malignant Syndrome (NMS)

Answer 2

• Fever, rigidity, autonomic instability, clouding of consciousness, elevated WBC/CPK
• Withhold neuroleptics, hydrate, consider dantrolene and/or bromocriptine
• Idiosyncratic, time-limited reaction

Question 3

Serotonin Syndrome

Answer 3

• Precipitated by used of two drugs with serotonin-enhancing properties (e.g. MAOI + SSRI)
• Altered mental status, fever, agitation, tremor, myoclonus, hyperrexia, ataxia, incoordination, diaphoresis, shivering, diarrhea
• Discontinue offending agents, benzos, consider cyproheptadine

Question 4

Tyramine reaction/Hypertensive crisis

Answer 4

• Precipitated by ingestion of tyramine containing foods while on MAOI’s
• Hypertension, headache, neck stiffness, sweating, nausea, vomiting, visual problems, Most serious consequences are stroke and possibly death
• Treat with nitroprusside or phentolamine

Question 5

Acute Dystonia

Answer 5

• Early, sudden onset of muscle spasm: eyes, tongue, jaw, neck; may lead to laryngospasm requiring intubation
• Treat with benztropine (congentin) or diphenhydramine (Benadryl)

Question 6

Lithium toxicity

Answer 6

• May occur at any Li level (usually > 1.5)
• Nausea, vomiting, slurred speech, ataxia, incoordination, myoclonus, hyperreflexia, seizures, nephrogenic diabetes insipidus, delirium, coma
• Discontinue Li, hydrate aggressively, consider hemodialysis

Question 7

TCA toxicity

Answer 7

• Primarily anticholinergic effects; cardiac conduction disturbances, hypotension, respiratory depression, agitation, hallucinations
• CNS stimulation, depression, seizures
• monitor ECG, activated charcoal, cathartics, supportive treatment