Psychiatric emergencies Flashcards
Symptoms and signs of lithium toxicity
- GI: severe nausea/vomiting and diarrhea
- cerebellar: ataxia, slurred speech, lack of coordination
- cerebral: drowsiness, myoclonus, tremor, upper motor neuron signs, seizures, delirium, coma
AMH
Mild-to-moderate: blurred vision, increasing diarrhoea, nausea, vomiting, muscle weakness, drowsiness, apathy, ataxia, flu-like illness
Severe: increased muscle tone, hyperreflexia, myoclonic jerks, coarse tremor, dysarthria, disorientation, psychosis, seizures, coma
Management of lithium toxicity
Management
- discontinue lithium for several doses and begin again at a lower dose when lithium level has fallen to a non-toxic range
- serum lithium levels, BUN, electrolytes
- saline infusion
- hemodialysis if lithium >2 mmol/L, coma, shock, severe dehydration, failure to respond to treatment after 24 h, or deterioration
Neuroleptic malignant syndrome - symptoms + risk factors
FARM
Fever
Autonomic changes (e.g. increased HR/BP, sweating)
Rigidity of muscles
Mental status changes (e.g. confusion)
psychiatric emergency
- due to massive dopamine blockade; increased incidence with high potency and depot neuroleptics
risk factors
- medication factors: sudden increase in dosage, starting a new drug
- patient factors: medical illness, dehydration, exhaustion, poor nutrition, external heat load, male, young adults
Treatment of neuroleptic malignant syndrome
- supportive
- discontinue drug, hydration, cooling blankets, dantrolene (hydrantoin derivative, used as a muscle relaxant), bromocriptine (DA agonist)
Clinical features of serotonin syndrome
Time course + complications of serotonin syndrome?
In most cases, is a self-limiting condition and will improve on cessation of the offending drugs
Mild-moderate cases usually resolve in 24-72 hours
In severe cases patients require intensive care as the syndrome may be complicated by:
- severe hyperthermia
- rhabdomyolysis
- disseminated intravascular coagulation
- and/or adult respiratory distress syndrome
What are some drugs implicated in severe serotonin syndrome?
Approach to patients with overdose of paracetamol
PARACETAMOL
- treatment - N-acetylcysteine
Approach to patients with overdose of opioids
- symptoms
- key investigations
- management
Symptoms
- pinpoint pupils
- unconsciousness
- respiratory depression.
Key investigations
- Blood gases—consider because partial pressure of carbon dioxide (PaCO2) is the best measure of hypoventilation.
- Chest X-ray—required in patients with hypoxia in the absence of respiratory depression, or patients who have persistent hypoxia despite ventilatory support or reversal with naloxone.
- ECG—required for methadone and dextropropoxyphene.
Management
- ABC
- IV naloxone
Approach to patients with overdose of benzodiazapines
- symptoms
- key investigations
- management
SYMPTOMS
- CNS effects—drowsiness, sedation, coma, respiratory depression, slurred speech, incoordination, unsteady gait, and impaired attention or memory
- cardiac effects—bradycardia and hypotension (with very large overdoses)
- other effects—hypothermia (with very large overdoses).
INVESTIGATIONS
- BSL
- ECG
- urine toxicology screen
- FBC
- serum ethanol level
MANAGEMENT
- ABCs - may need intubation
- Flumazenil - only used in a few situations:
- in elderly or other patients with respiratory disease (eg COPD) where intubation should be avoided, as CNS depression with poor respiratory effort and poor cough may result in atelectasis and respiratory infection
- in the treatment of CNS depression due to iatrogenic over-treatment with benzodiazepines (eg in procedural sedation), where short-term use of flumazenil may be beneficial
- unintentional lone paediatric benzodiazepine ingestion with compromised airway and breathing
- benzodiazepine overdose resulting in compromised airway or breathing in settings where resources for intubation are not available.
Investigations for NMS
- CK - high CK >1000
- FBC - Leucocytosis, wbc >10000
- Elevated liver enzymes
- Creatinine, BUN
- Serum electorlytes
- Urine myoglobin
Risk factors for NMS
- First 2 weeks of treatment
- Higher dose = higher risk
- High potency drugs – typical antipsychotics
- Parenteral – depot injection
- Rapid dose escalation
usually in young males on IM antipsychotics
Significants of dehydration in a patient who takes lithium
Excreted almost entirely by the kidneys and is handled in a manner similar to sodium
Volume depletion or renal impairment from ANY causes increases lithium reabsorption = at increased risk of lithium toxicity
Environmental factors contributing to violence/aggression
- Spatial crowding
- Limited or no staff training in assault prevention
- Younger staff with less experience
- Stretched of time with nothing to do - boredom, important to keep patient engaged (eg. Watch TV, magazine to read)
- Lack of peer supports and other natural supports
Behavioural indicators of aggression
- Signs of agitation – pacing, clenching fists, hands, teeth, tremors/sweating
- Threats
- Staring or hypervigilance
- Brooding over event in which treated unfairly
- Evidence of making plans to injure
