Psychiatric Emergencies

Question 1

What is a psych emergency?

Answer 1

• A psychiatric emergency is any disturbance in thought, feeling or actions for which immediate therapeutic intervention is necessary
• Emergencies can be classified as major, minor, and emergencies related to medical causes

Question 2

What are examples of major emergencies?

Answer 2

• Suicidal patients

* Agitated & violent patients

Question 3

What are examples of minor emergencies?

Answer 3

• Greif reaction
• Rape
• Disaster
• Panic attacks

Question 4

What are examples of medical emergencies in psych?

Answer 4

• Delirium
• Neuroleptic Malignant Syndrome
• Serotonin syndrome
• Overdose of common psychiatric medications
• Overdose & withdrawal from addicting substance

Question 5

What are the basic principles in managing psychiatric emergencies?

Answer 5

Predications of risk of agitation
Prevention of behaviour escalating once patients begins disturbed
Use of early interventions to ensure safety of the patients and staff

Question 6

What are the issues to consider in management?

Answer 6

need for admission, MHA, MCA
level of security needed 
level of observation 
need for medication 
need for physical restraint

Question 7

How should you assess a psychiatric emergency?

Answer 7

Take a full history
Mental state examination
Violent behaviour
Assessment for need for urgent treatment or admission

Question 8

Why should de-escalation be used?

Answer 8

aim to predict the possible violence and de-escalate the situation

Question 9

What is the pharmacological management?

Answer 9

rapid tranquillisation - calms patient, lorazepam is widely used
ensure CPR facilities are available

Question 10

What are the potential SEs of pharmacological management (lorazepam)?

Answer 10

acute dystonia
hypotension 
neuroleptic malignant syndrome 
respiratory distress syndrome 
arrthymias

Question 11

What is neuroleptic malignant syndrome (NMS)?

Answer 11

Potentially serious and fatal adverse effect of all antipsychotic medication

Question 12

What are the RFs for NMS?

Answer 12

previous NMS
agitation
dehydration
intramuscular therapy 
rapid antipsychotic med increase

Question 13

What are the symptoms of NMS?

Answer 13

fever 
diaphoresis 
rigidity 
confusion 
fluctuating consciousness 
autonomic instability

Question 14

What would lab investigations show in a NMS?

Answer 14

CK is frequently raise
leucocytosis
deranged liver function tests

Question 15

What is the treatment for NMS?

Answer 15

• withdraw antipsychotic meds
• monitor patient more closely
• consult a psychiatrist
• consider benzo for sedation
• rehydration
• dopamine agonist may be used

Question 16

What is acute dystonia?

Answer 16

• reversible extrapyramidal SEs that occur after antipsychotic meds have been administered
• muscle spasm anywhere in the body

Question 17

What causes acute dystonia?

Answer 17

high potency D2 receptor meds like haloperidol

Question 18

How is acute dystonia treated?

Answer 18

Responds well to anticholinergic medications

i.e. Procyclidine (IM/IV fastest)

Check for cyanosis, may need oxygen or intubation

Rehydrate

Question 19

Why does lithium toxicity occur?

Answer 19

excreted almost entirely by the kidneys - renal function important

Question 20

Why is lithium toxicity fatal?

Answer 20

untreated lithium toxicity is fatal

Question 21

What are the early symptoms of lithium toxicity?

Answer 21

marked tremor, anorexia, n&v, diarrhoea

Question 22

What are the late symptoms of lithium toxicity?

Answer 22

restlessness, muscle fasciculations

Question 23

What is the treatment of lithium toxicity?

Answer 23

Stop lithium
adequate hydration

if severe - patient may require forced diuresis or haemodialysis

Question 24

What is serotonin syndrome?

Answer 24

rare, life threatening conditions

Question 25

What are the common causes of serotonin syndrome?

Answer 25

when patients are switched over from one antidepressant to another or when a combo of antidepressants is used

Question 26

What are the symptoms of serotonin syndrome?

Answer 26

restlessness, confusion, agitation, hyperthermia, GI upset, myoclonus, rigidity, tremors, ataxia

Question 27

What is the treatment of serotonin syndrome?

Answer 27

stop medication
symptomatic treatment with rehydration
bentos can be used for agitation

Question 28

What are the differences between NMS and serotonin syndrome?

Onset
Progression
Muscle rigidity
Activity

Answer 28

NMS 
ONSET - slow
PROGRESSION - slow
MUSCLE RIGIDITY - severe
ACTIVITY - bradykinesia 

Serotonin syndrome 
ONSET - rapid
PROGRESSION - rapid 
MUSCLE RIGIDITY - less severe 
ACTIVITY - hyperkinesia