Psychiatric emergencies

Question 1

What is Neuroleptic malignant syndrome

Recognise/treat

Answer 1

Side effect of too many anti-psychotics 
FEVER (D2 blockage @hypothalamus ^temp)
Rigidity/stiffness
altered mental state
autonomic dysfunction (pale, ^HR, sweating, tremor etc)

Gradual (1-3day) onset within 4weeks of starting antipsychotic drugs

Question 2

Delirium tremens

What is it - name symptoms

Answer 2

Change in mental state 24-72 hours after stopping alcohol
Hallucinations
Confusion
Delusions 
Severe agitation
Seizures

Question 3

Delirium tremens

How do you manage it

Answer 3

ABC
Diazepam
Thiamine
?Magnesium to protect from seizures/arrthymias

Question 4

Wernicke’s encephalopathy

Name some causes

Answer 4

Chronic alcohol consumption
= reduced thiamine intake and reduced absorption in GI tract

Brain tumour
Malabsorption / prolonged vomiting
Chemotherapy

Question 5

Wernicke’s encephalopathy

Name the triad of symptoms

Answer 5

1) confusion
2) wide based gait ataxia
3) opthalmoplegia (nystagmus, conjugate gaze, bilateral lateral recrus palsies)

Also bad memory, low bp, cold, ptôsis etc

Question 6

Wernicke’s encephalopathy
Treatment
Before or after glucose if required?

Answer 6

Thiamine

To be given BEFORE glucose if this is required

Question 7

Wernicke’s encephalopathy

can lead to what if untreated

Answer 7

Korsakoff syndrome
Thiamine deficiency causes damage to hypothalamus and cerebral atrophy
Cant make new memories - confabulates
no insight and apathy

Question 8

Symptoms of lithium toxicity

Answer 8

• Anorexia, diarrhoea and vomiting.
• Drowsiness, apathy, restlessness.
• Dysarthria.
• Dizziness, ataxia, uncoordinated, muscle twitching, coarse tremor

If severe: 
•Hyperreflexia, convulsions.
•Collapse, coma, death
•Renal failure
•Hypokalaemia

Question 9

Treatment of lithium toxicity

Answer 9

Stop lithium, check level

encourage fluids
stop diuretics
monitor electrolytes renal function

Question 10

Lithium side effects

Answer 10

Polyuria/dipsia - lithium competes with ADH receptors
Hypothyroidism
Weight gain
Muscles twitching

Question 11

What is an acute dystonic reaction - what does it look like

Answer 11

Extrapyramidal side effect - sustained muscle contractions, twitching, repetitive movements or abnormal postures

rarely life threatening

because the dopamine blockade causes excessive striatal ACh output

Question 12

How long does an acute dystonic reaction last for?

Answer 12

a few days untreated

usually manifests a few hours after taking a causative drug

Question 13

What causes an acute dystonic reaction?

Answer 13

Anti-psychotics most importantly

but also: SSRIs, recreational drugs and other things

Question 14

First line treatment of an acute dystonic reaction

Answer 14

Benztropine

Question 15

What is Neuroleptic malignant syndrome, what causes it

Answer 15

Potentially life threatening reaction to neuroleptic/antipsychotic drugs

Question 16

Neuroleptic malignant syndrome - symptoms

Answer 16

Fever
Muscular rigidity (lead pipe)
Altered mental state
Autonomic dysfunction (pale, HR^, BP change, sweaty, tremor, incontinence)

Because D2 block in hypothalamus messes with temperature regulation

occurs within 10 days in 90%
Gradual onset over 1-3 days

Question 17

Serotonin syndrome - what is it - drugs which cause it

Answer 17

Serotonin excess - excessive stimulation of the CNS - usually from SSRIs, SNRIs etc - other drugs can cause it too

Question 18

Serotonin syndrome - triad of symptoms

Answer 18

1 Autonomic hyperactivity (HTN, HR^, hyperthermia, ^bowel sounds, sweating)
2 Neuromuscular abnormality (tremor, clonus, ocular clonus, hypertonicity, hyperreflexia)
3 Mental state changes (anxious, agitated, confused, coma)

Usually appear within 6 hours of taking the provoking drug

Question 19

Paracetamol overdose - treatment

Answer 19

N-acetylcysteine

Question 20

What is Catatonia

3 Classic features

Answer 20

abnormality of movement and behaviour arising from a disturbed mental state

1. Motoric immobility - catalepsy, waxy flexibility, stupor
2. Mutism - verbally minimally responsive.
3. Negativism - involuntary resistance to passive movement, or involuntary oppositional behaviour

Question 21

What is stupor

Answer 21

extreme hypoactivity, minimal response to stimuli, including painful ones

Question 22

What is Catalepsy

Answer 22

Catalepsy is a state characterised by a patient keeping an uncomfortable, rigid and fixed posture despite external stimulus or resistance. There may also be decreased sensitivity to pain. It is a feature seen in catatonia

Question 23

Catatonia - management

Answer 23

treat underlying cause

psychiatric causes:
NMS, severe depression, psychosis,drugs etc

Question 24

Define delirium

Answer 24

an acute, transient and reversible state of confusion, usually the result of other organic processes (infection, drugs, dehydration etc.), the onset is acute and the cognition of the patient can be highly fluctuant over a short period of time.

acute confusional state

Question 25

Hyperactive delirium symptoms

Answer 25

Agitation
Delusions
Hallucination
Wandering
Aggression

Question 26

Hypoactive delirium symptoms

Answer 26

Lethargy
Slowness with everyday tasks
Excessive sleeping
Inattention

looks like depression

Question 27

Causes of delirium

CHIMPS PHONED

Answer 27

Constipation
Hypoxia
Infection
Metabolic disturbance (inc endocrine)
Pain
Sleeplessness/surgery
Prescriptions
Hypothermia/pyrexia
Organ dysfunction (hepatic or renal impairment)
Nutrition
Environmental changes
Drugs (over the counter, illicit, recreational, their partner/neighbour/pets’, alcohol and smoking)

Question 28

Delirium management

Answer 28

Supportive - have a clock, consistent staff etc, relax, TV, pleasant environment, allow wandering as much as possible
haloperidol/olanzapine only if necessary