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Emergency Medicine > Psychiatric Emergencies > Flashcards

Psychiatric Emergencies Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Approach to Belligerent Pt

A
  • Utox
  • Chem 10
  • CBC
  • VS
  • PE
  • patient and personal SAFETY
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2
Q

Approach w/ Intoxicated Pt

A

expect withdrawal

  • discharge from ED
  • CIWA- alcohol withdrawal assessment
  • consider infectious process

cannot perform psych eval if intoxicated

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3
Q

Approach w/ Cocaine Pt

A
  • check EKG to ensure no MI
  • Tx (depends on agitation/paranoia)
    • no tx
    • benzos
    • antipsychotics
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4
Q

Behavioral Predictors of Violence

A
  • angry words
  • loud language
  • abuse language
  • physical agitation (fist, pacing, akasthisia- restlessness)
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5
Q

Assessing Risk of Violence

A
  • history of violence
  • circumstances of violence
  • substance dependence/abuse (30x)
  • antisocial/borderline personality disorder (100x)
  • mental illness (9x)
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6
Q

How to De-escalate

A
  • calm voice
  • sit down w/ patient
  • maintain 6ft distance
  • establish rapport
  • listen to pt concerns for 1st 5 minutes
  • pharmacologic or physical restraints if needed
    • Lorazepam 1-2mg IM/IV (PO q4-6h)
    • NOT w/ alcohol (additive effect)
    • 5% can have increased agitation
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7
Q

Antipsychotic Dopaminergic Pathways

(for agitation suppression)

A
  • Nigro-Striatal
    • substantial nigra to basal ganglia
    • movement (tardive dyskinesia, akathisia)
  • Meso-Limbic
    • VTA to nucleus accumbens
    • reward pathway (+sx of schizophrenia)
  • Meso-Cortical
    • VTA to cortex
    • motivation/emotional response (-sx of schizophrenia- more debilitating, diff 2 tx)
  • Tubulo-Infundibular
    • hypothalamus to posterior pituitary
    • hypoprolactinemia in untreated but D2 blockade can cause hyperprolactenemia)
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8
Q

Typical Antipsychotics

A

Strong D2 antagonism in meso-limbic and meso-cortical pathways

  • significant extrapyramidal sx (EPS)
  • strong CYP-450 metabolism (lots of drug interactions and grapefruit)
  • high-potency: minimally sedating, more weight gain, higher EPS risk

low-potency: quite sedating, more anticholinergic (bradycardia, GI upset), lower risk EPS

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9
Q

Atypical Antipsychotics

A

Bind D2 receptors but higher affinity for serotonin (5HT) receptors

  • less risk EPS
  • higher risk metabolic side-effects and weight gain
  • Cloozapine slightly different
    • shorter half-life (less EPS)
    • serious risk of agranulocytisis (NOT a PRN/ED med!)
    • difficult to restart- keep pt on titrated level
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10
Q

IM Antipsychotics

A
  • Ziprasidone (Geodon) 20mg IM q4h or 10mg q2h not to exceed (NTE) 40mg/24h
  • Haloperidol (Haldol) 1-5mg IM q1h NTE 20-30mg/24h
  • Olanzapine (Zyprexa) 5-10mg IM NTE 20mg/24h (risk of hypotension in elderly)
  • Droperidol (Inapsine) 2.5-5mg IM/IV - BLACK BOX for arrhythmias
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11
Q

PO Antipsychotics

A
  • Risperidone (Risperdal) 1-2mg PO NTE 6mg/24h (Risperdal M-tab rapid melting tab)
  • Olanzapine 10-20mg PO NTE 20mg/24h (Zydis rapid melting tab)
  • Haloperidol 1-5mg PO q1-2h NTE 30mg/24h

*can ask pt if they’ve had prev success w/ drug

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12
Q

Extrapyramidal Symptoms

A

muscle tightness in limbs, tongue/neck tightness, sense of choking more rare

  • Haldol most likely, then Risperidone
  • Atypical have less risk
  • MC in young male AA and older women
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13
Q

EPS Treatment

A
  • O2 if breathing problems
  • Diphenhydramine (Benadryl) 50mg PO/IM/IV q4-5h
  • Benztropine (Cogentin) 1-2mg PO/IM q8-12h
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14
Q

Serotonin Syndrome

(MANY SSRIs)

A
  • mental changes
    • anxiety, confusion, restlessness, agitation, decreased LOC
  • neuromuscular abnormalities
    • tremor, hyperreflexia, clonus, rigidity, wrist or ocular myoclonus, ataxia
  • autonomic hyperactivity
    • diaphoresis, hyperthermia, shivering, mydriasis, nausea, diarrhea
  • VS: tachycardia, labile BP changes
  • S/s seen on a spectrum
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15
Q

Seratonin Syndrome Tx

A
  • d/c all serotonin agents
  • supportive care (often no tx required)
  • consult medical toxicologist, clinical pharmacologist, or poison control
  • Cyproheptadine (serotonin antagonist)
  • intubation and ventilation if severe w/ hyperthermia (>41.1 C)
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16
Q

What is needed w/ overdose

once pt medically stable

A

suicide assessment

  • Ideation
    • acute vs. chronic / passive vs. active
    • plan, lethalilty of method, intent?
  • Demographic/Environment
    • caucasian or native american
    • male
    • >65
    • unmarried or living alone
    • unemployed
    • family hx
    • recent loss
    • lethal means available
    • chronic illness
  • Clinical Factors
    • hx of suicide attempt
    • substance abuse
    • agitation
    • psychiatric illness/symptoms or psych hospitalization
    • hopelessness or apathy
    • sleep disturbance
    • social isolation
      *
17
Q

Suicide Protective Factors

A
  • actively making future plans
  • verbalize hope for future
  • cognitive flexibility
  • responsibility to dependents
  • therapeutic relationship w/ tx provider, social network or family
  • belief that suicide is immoral
  • fear of social disapproval
  • fear of act
18
Q

Plan if not admitting patient

A

make modifications to risk factors before d/c

  • who will they stay with
  • contingency plan if SI returns: names, phone numbers, places to go
  • plan for management of sx (anxiety, drug cravings)
  • money questions:
    • why do you feel you can be safe now
    • what’s different vs. when you came to ED
19
Q

Plan if admitting patient

A
  • evaluate need for sitter
  • admit to psychiatric unit if available
  • remember pts can commit suicide while in hospital too
20
Q

Key Points for Multi-facited Cases

A
  • keep broad differential in mind
  • watch for evolution of sx and clinical findings
  • agitation can be managed behaviorally and pharmacologically
  • ALWAYS assess safety of patients and self
  • ALWAYS err on side of safety

Emergency Medicine (2 decks)

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