Psychiatric Emergencies Flashcards
Define Akathisia
A medication induced syndrome of motor restlessness, characterised by
- Objective motor restlessness
- Subjective sense of inner restlessness
- A compulsion to move
- Subjective dysphoria
Onset is within 6 days – 6 weeks after drug initiation
What are the risk factors for Akathisia?
Typical antipsychotics
Rapid dose escalation
Older patients
Females
Presence of negative symptoms
Presence of cognitive symptoms
Presence of affective symptoms
Iron deficiency
What is the management of Akathisia?
Regularly asses for akathisia
- 6 monthly for Typical AP
- Annually for Atypical AP
Lower AP dose
If fails then, Change AP drug
- Olanzapine
- Quetiapine
- Clozapine
If fails then add a beta-blocker
- Propofol 30-80mg daily PO
If fails then, add Cyproheptadine 16mg daily PO
If mood symptoms are present consider mirtazapine (serotonin antagonist)
If fails then, add short course benzodiazepine
- Clonazepam 1-2mg 8 hourly
If fails then, Stop benzo and try clonidine 0.2-0.8mg daily PO
Each step must be tried for a minimum of 1 month
What must be done before prescribing lithium?
Kidney function – renal disorders
Thyroid function – inhibitory effects on thyroid
Cardiac function – arrhythmias
Pregnancy test in females
What are the signs and symptoms of lithium toxicity?
N & V
Diarrhoea
Abdominal pain
Ataxia
Tremors
Stupor
Clouded consciousness
Disorientation
Hyperreflexia
Coma
Death
What is the therapeutic blood level of lithium?
0.5 - 1.2mmol/L
What is the toxic blood level of lithium?
> 1.5mmol/L
What is the management of lithium toxicity?
Transfer to the emergency medical ward
Stop lithium treatment
Supportive management –Rehydrate
Do a complete physical exam and biochemical investigations
- Lithium level
- U & E
- FBC
- LFTs
- Pregnancy test
- ECG
Prevent further absorption
- Gastric lavage
- Induce emesis with activated charcoal
Haemodialysis for severe cases
Discuss lithium recommencement
Define Serotonin Syndrome
A rare but life-threatening adverse reaction to SSRIs, especially when switching from an SSRI to an MAOI due to overstimulation of the serotonin system
What are the symptoms of serotonin syndrome?
i. Nausea
ii. Diarrhea
iii. Palpitations
iv. Chills
v. Restlessness
vi. Confusion
vii. Lethargy
viii. Poor coordination
What are the core clinical features of serotonin syndrome?
Altered LOC
Fever
Myoclonus
What is the management of Serotonin Syndrome?
Discontinue medication and emergency medical care as needed
Supportive therapy
Discuss with specialist
What are the symptoms of acute dystonia?
- muscle spasm of the neck
- contraction of the periorbital and orbital muscle
- protrusion of the tongue
- locked jaw
- difficulty swallowing
- abnormal posture and slow movement of limbs
What is the management of acute dystonia?
- assess which muscle group is involved
- immediately stop antipsychotic drug
- give anticholinergic - biperidem 2-5mg IV
- if severe - sedate, intubate and transfer
- once resolved, reassure and change or lower medication
Approach to the aggressive patient
Step 1:
- Before confronting the patient gather information
- Psych Hx
- Previous aggression
- Medical conditions - DIMTOP
- Substance use Hx
- Contact with patient
- Try to diffuse situation using minimal physical impact
- Grant reasonable requests
- Have adequate support
- If weapon - remove everyone & call security
- If patient needs restraint - 5 points + 1 additional person to administer sedative
Step 2:
- Immediate medical management
- Psychiatric evaluation
- Physical exam
- Side-room investigations - dipstick, HGT
Step 3: Diagnosis and management
- Determine whether delirius/psychotic
- Delirium - transfer to medical ward, sedate with haloperidol 5-10mg 4-8hrly IM
- Psychotic - sedate with diazepam 10-20mg IV or Lorazepam 1-4mg IM
- Expected response time: Diazepam 10 mins, Lorazepam 30 mins, Haloperidol 30 mins
- If unmanageable - repeat up to 3 doses
- Max dose: Diazepam 60mg, Lorazepam 4mg. Haloperidol 60mg
- Contact consultant if no improvement
- As soon as manageable transfer to safe place
- Remain cognisant of legal implications & certify if needed
