Psychiatric emergencies Flashcards
How are psychiatric emergencies classified?
major, minor and emergenices related to medical causes Around 30% of emergency patients are suicidal, 10% are violent, 40% require hospital admission Major: Suicidal Agitated and violent Minor: Grief reaction Rape Disaster Panic attack
What are common medical emergencies?
Delirium Neuroleptic malignant syndrome Serotonin syndrome OD of common psychiatric medications OD and withdrawal from addicting substance
Whta is delirium?
Transient, potentially reversible cerebral dysfunction with acute or subacute onset that manifest with fluctuating mental state abnormalities
Global cognitive impairment associated with behavioural abnormalities
10-30%
10-15% elderly people admitted to hospital, another 10-40% develop it during their stay
60% of delirium is superimposed on dementia
Due to alterations in Ch or NA neurotransmitter systems, or interruption of the BBB
What is the ICD-10 criteria for delirium?
Clouding of consciousness- reduced awareness of environment, reduced focus, shifting attention
Disturbed cognition- Impaired immediate recall and recent memory disorientation in time, place or person
Variable anxiety levels, increased reaction time, altered speech flow, enhanced starlet reaction
Insomnia, daytime drowsiness, reversed sleep-wake cycle, disturbing dreams/nightmares
What are the types of delirium?
Hyperactive- heightened arousal, restless, agitated aggressive Hypoactive- withdrawn, quiet, sleepy Mixed Delirium superimposed on dementia persistent delirium
What are raw causes of delirium?
INFECTION - HIV, Sepsis, pneumonia
WITHDRAWAL - alcohol, barbiturates, sedatives
ACUTE METABOLIC - acidosis, alkalosis, electrolyte imbalance, hepatic failure, renal
failure
TRAUMA - head injury, heat stroke, post-op, severe burns
CNS PATHOLOGY - abscess, haemorrhage, SDH, stroke, seizures, tumours,
meningitis, encephalitis, syphilis
HYPOXIA - anaemia, CO poisoning, hypotension, CCF
DEFICIENCIES - B12, folate, niacin, thiamine
ENDOCRINE - hyper/hypoadrenocorticism, hyper/hypoglycaemia, hyperparathroid
ACUTE VASCULAR - hypertensive encephalopathy, stroke, arrhythmia, shock
TOXINS/DRUGS - illicit, prescription, solvents
HEAVY METALS - lead, managnese, mercury
What is the assessment for delirium?
History - patient, collateral and notes Consider physical causes - infection, constipation, dehydration, medications, alcohol withdrawal Risk assessment Complete a BASELINE MoCA
What are the investigations for delirium?
Infection - culture, urinalysis, FBC, CRP, CXR Medication review Metabolic/endocrine Cardiac - ECG Hypoxia - ABGs Neuro - CT brain
What is the management for delirium?
Identify and treat precipitating cause
Provide a calm environment and supportive measures
Involve family and carer
May refer to psychiatric team
Avoid sedation unless severely agitated
Review patient regularly
Prognosis- average duration is 7 days, increased risk of mortality- increased by 75% in elderly population
What is acute behavioural disturbance?
Develop in patients with mental health illnesses at any time in the course of their illness, or as a manifestation of an underlying organic illness
Patients become agitated/aggressive during an acute episode of illness, eg mania/schizophrenia
- May be due to psychotic symptoms
- Due to non-psychotic symptoms
- Use of illicit drugs
What are the basic principles of acute behavioural disturbance?
Predictions of risk of agitation
Prevention of behaviour escalating once patient becomes disturbed
Use interventions to ensure safety of patients and staff
What are the warning signs for an increased risk of aggression?
Persecutory delusions Delusions of passivity Actual threats of violence Emotional state linked to violence Behaviour Limited insight
What are the warning signs for violent behaviour?
Angry facial expression Restless or pacing Shouting Prolonged eye contact Refusal to cooperate delusions/hallucinations with violent content Verbal threats/thoughts of violence Blocking escape routes Evidence of arousal - SNS activation
How should physical restraint be carried out?
Only used when other measures have failed/inappropriate
One member of staff should be in charge and carry out:
Encourage patient to move to a separate room/area
Speak confidently, slowly and clearly
Adopt a non-threatening body posture and verbal communication
Pre-warn the patient
Explore concerns
Develop a rapport with patient
Request patient to put any weapons down
What should be considered when giving rapid tranquillisation?
Calm the patient without sedating them and reduce risk of violence and harm
Give orally where possible
Always consult a senior doctor
Use minimum dose of medications
Choose one with a rapid onset, short-acting, minimal side-effects and easily reversible effects
What are the choices of medications for rapid tranquillisation?
Benzodiazepines
Lorazepam has quick onset, short duration, safe and tolerable
Midazolam has 15 min onset after IM, 3-5 for IV
Diazepam has a longer half life and when given IM has an erratic and
slow absorption
○ Antipsychotics - haloperidol, olanzapine
What are other considerations for rapid tranquillisation?
Ensure cardiopulmonary resuscitation facilities are available
Need to carry out physical observation after giving medication - pulse, BP, temp,
RR, oxygen sats
If given IM - maintain patients dignity
What are the complications fo benzodiazepines?
Acute dystonia- severe painful muscle stiffness
Hypotension- orthostatic or <50 diastolic
Respiratory depression-
Arrhythmias- irregular pulse or pulse rate <50
What is the management for the complications of benzodiazepines?
Acute dystonia:
Procyclidine 5-10mg IM/IV or benzotropine 1-2mg
Hypotension:
Lie patient flat and raise legs, monitor closely
Respiratory depression:
Give 02, raise legs, if RR <10 give flumazenil 200mg IV over 15 seconds
Arrhythmias:
Monitor closely
Liaise with medical team
What are the risk factors for neuroleptic malignant syndrome?
Previous NMS Known cerebral compromise Alcoholism Agitation, overactivity, catatonia Dehydration IM therapy Recent/rapid antipsychotic dose increase Rapid dose reduction/abrupt withdrawal of anticholinergic medication High doses of antipsychotic medication
What are the symptoms for neuroleptic malignant syndrome?
Variable presentation Fever Diaphoresis Rigidity Confusion Fluctuating consciousness Autonomic instability
What are the investigations for neuroleptic malignant syndrome?
CK is frequently raised >1000 units/L
Leucocytosis and deranged LFTs
What is the treatment for neuroleptic malignant syndrome?
Withdraw antipsychotic Monitor tempr, BP and pulse Consider benzo for sedation Rehydration Dopamine agonist - Bromocriptine
What is acute dystonia?
Reversible extrapyramidal side effect
Muscle spasms, immediate or delayed
Causes distress to patients and can be life-threatening if it includes laryngeal muscles
usually idiosyncratic and unpredictable
More common in high potency D2 receptor medications- e.g haloperidol
Occurs in around 10%- more common in young men
What is the treatment for acute dystonia?
Dystonia usually responds well to anticholinergic medications, eg
procyclidine
- Can be taken IM or IV
- Check for cyanosis and give oxygen if required
What is serotonin syndrome?
Rare, potentially life-threatening ondition occurring during initiation/increased dose of serotonergic medication
Caused by:
Increased serotonin synthesis/release
- Reduced serotonin uptake/metabolism
- Direct serotonin receptor activation
Occurs when patients switch antidepressants or when a combination are used
Occurs when taken alongside triptans, Wort, drugs
What are the symptoms of serotonin syndrome?
Restlessness Confusion Agitation Hyperthermia GI upset Tachycardia Hypo/hypertension Mydriasis Myoclonus Rigidity Tremors Hyperreflexia
What is the treatment for serotonin syndrome?
Stop medication
Rehydration
Benzo for agitation
If OD - gastric lavage
What are the differences between neuroleptic malignant syndrome and serotonin syndrome?
NMS: Onset slow (days to weeks) Progression slow (24-72 hours) Muscle rigidity severe (lead pipe) Bradykinesia Serotonin syndrome: Onset rapid Progression rapid Less severe muscle rigidity Hyperkinesia
