Psychiatric emergencies Flashcards by Apoorva Aji

What can cause a patient to become violent? (4)

Psychiatric condition, substance use, personality disorder developing because of a physical disorder. Or due to the ward environments- overcrowding, noise

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What would you do to prepare when going to see a violent patient? (3)

Stand so that there is nothing between you and the door, take an alarm, see the patient with family/friend/staff they are comfortable with

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What’s the first line treatment for a violent patient?

De-escalation - talk to them calmly, be sympathetic, address their concerns

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What is given first line in rapid tranquillisation? (2)

Oral lorazepam or oral haloperidol + promethazine

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What is given 2nd line in rapid tranquillisation? (1)

IM lorazepam

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What is required to be done by nurses/doctors after rapid tranquillisation is administered?

Patient will need regular physical examinations, vital signs, ECG, bloods- FBC, U&E

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If giving lorazepam in rapid tranquillisation, what other drug is needed on hand and why?

Flumazenil- in case of respiratory depression (caused by lorazepam). It is a benzodiazepine antagonist.

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What are the first things to do when a patient presents with an overdose?

ABCDE. Find out what drug they took- from family/wrappers. Check serum levels as some drugs can be tested in serum eg. paracetamol, lithium, ethanol

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What is the treatment of overdose?

Reduce drug absorption- using activated charcoal and then give the antidote

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When is it best to give activated charcoal for best effect?

Within 1 hour

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What are the symptoms of a paracetamol overdose?

Usually asymptomatic- some nausea and vomiting. After time- RUQ pain, oliguria, liver failure

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What are the signs of a paracetamol OD?

Hyperventilation

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What is the antidote/treatment of a paracetamol OD?

N-acetylcysteine if <4h. If >4h=measure levels and plot on N-acetylcysteine diagram. If taken >10g= give N-acetylcystein anyway

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What are the symptoms of an opiate OD? (3)

low GCS, respiratory depression. Can have pulmonary oedema.

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What are the signs of an opiate OD? (2)

Hypoventilation, pinpoint pupils

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What is the antidote and treatment of an opiate OD?

Naloxone IV. Protect the airway.

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What are the symptoms of an antidepressant OD? (6)

Confusion, nausea, vomiting, hallucinations, tremor, seizures

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What are the signs of an antidepressant OD (2)

Dilated/big pupils in TCAs, tachyarrhythmias- QT prolongation

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What is the antidote and treatment of an antidepressant OD?

Cardiac monitoring and benzodiazepines if they start convulsing

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What is an important condition to think about when patients present with OD of antidepressant

Serotonin syndrome

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What are the symptoms of an aspirin OD? (3)

Ringing in ears, nausea, abdominal pain

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What are the signs of an aspirin OD (1)

Hyperventilation

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What is the antidote/therapy for an aspirin OD?

Haemodialysis and then sodium bicarbonate for the metabolic acidosis (occurs after the initial response alkalosis)

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What are the symptoms of a benzodiazepine OD? (4)

CNS depression- (decreased HR, RR, GCS), impaired balance, slurred speech, ataxia

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What are the signs of a benzodiazepine OD (1)

Hypoventilation

What is the antidote/therapy for a benzodiazepine OD?

Flumazenil (benzodiazepine antagonist) and supportive- protect airway

What are the symptoms of a CO OD? (4)

Tension type headache, nausea and vomiting, dizziness, confusion

What are the signs of a CO OD? (1)

Hyperventilation

What is the antidote/therapy of a CO OD?

100% oxygen or hyperbaric oxygen - if more severe

What are the symptoms of an iron (ferrous sulphate) OD? (3)

Abdominal pain, nausea and vomiting (can contain blood). Can go into hypovolaemic shock (pallor, dizziness, low BP, tachycardia)

What are the main risks later on in an iron (ferrous sulphate) OD? (2)

Brain and liver damage due to metabolic acidosis and the iron goes deeper in the body

What is the antidote/therapy of an iron (ferrous sulphate) OD?

Iron chelating agent: desferrioxamine

What are the symptoms of a methanol OD? (4)

CNS depression (dec HR,RR, GCS), nausea and vomiting, lack of coordination, blurred vision

What are the signs of a methanol OD? (1)

Dilated pupils

What is the antidote/therapy of a methanol OD? How does it work?

Ethanol infusion. Ethanol blocks the ethanol dehydrogenase enzyme so stops the breakdown of methanol to its toxic metabolites and is excreted by the kidneys without being used

What are 2 things that need to be especially monitored when a patient presents with a methanol OD?

Renal function and glucose

Name 3 drugs that could cause hypoventilation in overdose?

Opiates, benzodiazepines and alcohol

Name 3 drugs that could cause hyperventilation in overdose?

Aspirin, paracetamol, carbon monoxide

Name 3 drugs/chemicals that could cause pinpoint pupils in overdose?

Opiates, organophosphates- insecticides, herbicides

Name 3 drugs that could cause dilated/big pupils in overdose?

Methanol, TCAs, LSD

Name 3 drugs that could cause tachyarrhythmias in overdose?

Antidepressants- TCAs, caffeine, digoxin

Name 3 drugs that could cause bradycardia in overdose

Beta blockers, digoxin, ecstasy

Name 3 drugs that could cause hypertension in overdose

Cocaine, Amphetamines, Ecstasy

Name 3 drugs that could cause hyperthermia in overdose

Antidepressants- SSRIs, Amphetamines, Ecstasy

What is the definition of alcohol addiction?

Repeated drinking with increased tolerance and a failure to stop. It significantly impacts their life as drinking is the priority

What is the CAGE questionnaire?

Have you ever felt you should cut down on your drinking? Have you ever felt annoyed when someone criticises your drinking? Have you ever felt guilty about your drinking? Have you ever needed an eye-opener- a drink in the morning?

What are the symptoms of alcohol withdrawal? (5)

They are stimulant effects due to the lack of depressant. Sweating, nausea, tremor, agitation, insomnia, depression. Can get seizures

What is Delirium Tremens?

The most severe form of alcohol withdrawal

What are the symptoms of delirium tremens?

Sweating, tremor, nausea AND psychotic symptoms- pink elephant hallucinations, delusions

What is the treatment of alcohol withdrawal?

ABCDE. IV Chlordiazepoxide for detox. IV Pabrinex- to replenish thaimine. IV diazepam for withdrawal seizures.

What is the cause of Wernicke's encephalopathy?

It is acute and due to thiamine/B12 deficiency - usually related to alcohol abuse

What is the triad of symptoms in Wernicke's encephalopathy?

Confusion, Ataxia (wide based gait), ophthalmoplegia (nystagmus, ptosis)

What is the treatment of Wernicke's encephalopathy

PO thiamine or PO pabrinex

What would you do if the patient had co-exisitng hypoglycaemia presenting with Wernicke's encephalopathy?

Give the thiamine before glucose so the Wernicke's isn't worsened by glucose administration

What is the cause of Korsakoff's syndrome?

It is chronic and due to hypothalamic damage and cerebral atrophy caused by thiamine deficiency

What are the symptoms of Korsakoff's syndrome? (3)

Confabulation, antegrade and retrograde amnesia, apathy

What are the signs of Korsakoff's syndrome? (3)

Ataxia, peripheral neuropathy, altered reflexes

What is the definition of delirium?

Sudden, fluctuating alteration in mental state and behaviour

What are the symptoms of delirium? (6)

Confusion, agitation, insomnia, worsened concentration, hallucinations, altered mood, reduced mobility, lack of cooperation

What are the 3 types of delirium?

Hyperactive- agitated/upset, hypoactive- drowsy/withdrawn or mixed

What are the causes of delirium?

``` V- vascular eg. stroke I- infection T- trauma eg. SDH A- autoimmune/allergy M- metabolic- hyperglycaemia I- iatrogenic/idiopathic N- neoplasm- brain tumours ``` C- congenital D- degenerative (dementia) or drug use - opiates E- endocrine - hyperthyroidism Constipation and urinary retention

What investigations would you do on someone you suspect has delirium?

Bloods- FBC, UE, TFT, LFT, blood gases, glucose, blood cultures- urine and blood. ECG, CXR, CT head, LP.

What is the treatment of delirium?

Treat the cause. Supportive- family visits, make surroundings similar to home - clock, calendar.

What medication can be given if a delirious patient is extremely agitated and a risk?

Low dose haloperidol

What medication can be given to a delirious patient that is extremely agitated due to alcohol withdrawal?

Diazepam

Withdrawal of benzodiazepines causes very severe symptoms. Which one cause the worst symptoms and why?

Lorazepam - symptoms appear faster because lorazepam is rapidly eliminated

What are the psychological symptoms in withdrawal of Benzos? (initially: 2. later: 5)

Anxiety or psychotic sx initially. Then months of irritability, insomnia, depression, panic

What are the GI symptoms in withdrawal of Benzos? (3)

Abdominal pain, D&V, dysphagia

What are the neurological symptoms in withdrawal of Benzos? (3)

Fasciculations, paraesthesia

What is the best way to administer benzodiazepines withdrawal?

Change to diazepam first to make withdrawal easier and withdraw by 2mg a week.