Psychiatric emergencies Flashcards
Why is alcohol a depressant?
It potentiates GABA which is a major inhibitory neurotransmitter in the CNS
This inhibits the electrical signal along the neuron
Alcohol inhibits major excitatory neurotransmitter glutamate
Disrupts the balance of activity of GABA and glutamate
What are the symptoms of alcohol withdrawal?
Pronounced tremor - can become a seizure and kill Sweating Vomiting Activation syndrome Seizures Hallucinations Delirium tremens
What are the symptoms of activation syndrome?
Tremors
Agitation
Rapid HR
Decreased BP
How do you treat alcohol withdrawal?
Medication - acamprostate calcium, disulfiram, nalmefene, naltexone, chlordiazepoxide, diazepam
Psychosocial - therapy, social support
What is delirium tremens?
A rapid onset condition of confusion occurring due to alcohol withdrawal
Most severe form of alcohol withdrawal manifested by altered mental state and sympathetic overdrive causing CVS collapse
When does delirium tremens occur?
3 days into withdrawal symptoms and may last 2-3 days
What are the symptoms of delirium tremens?
Tremors Agitation Confusion/disorientation Hallucinations Sensitivity to light and sounds Seizures Fever Tachycardia Hypertension
How do you manage delirium tremens?
Continually monitor vital signs Continuous sedation using benzodiazepines - chlordiazepoxide (long half life) - given in hospital, 2-3 days/taper down dose over 10 days if planned detoxification IV fluids Anti-psychotics Alcohol rehab
What is Wernicke’s encephalopathy?
Thiamine deficiency in severely dependent drinkers
Leads to focal areas of brain damage
Death of mammillary bodies
Why do dependent drinkers develop encephalopathy?
Poor diet/intake of vitamins
Poor GI absorption
High demand as metabolism of alcohol depends on thiamine as co-enzyme
What is the role of thiamine in the brain?
Involved in lipid (myelin sheath) and carbohydrate metabolism, production of amino acids and production of glucose derived neurotransmitters
What is the complication of Wernicke’s encephalopathy?
Korsakoff’s syndrome
What is Korsakoff’s syndrome?
Hypothalamic damage due to thiamine deficiency
Decreased ability to acquire new memories, confabulation, lack of insight and apathy
What are the symptoms of Wernicke’s encephalopathy?
Confusion Ataxia Ophthalmoplegia (nystagmus, lateral rectus/conjugate nerve palsies) Hypotension Hypothermia Reduced consciousness
How is Wernicke’s encephalopathy treated?
Urgent thiamine
What is serotonin syndrome?
Toxic syndrome of too much serotonin in the brain
What is the triad of symptoms of serotonin syndrome?
Neuromuscular abnormalities
Altered mental state
Autonomic dysfunction
What can cause serotonin syndrome?
Co-administration of anti-depressants
Often occurs with SSRI/SNRI with other medication raising serotonin level
St John’s wort
What are the symptoms of serotonin syndrome?
Confusion Agitation Muscle twitching Sweating Shivering Diarrhoea
How do you treat serotonin syndrome?
Depends on presentation
Ranges from supportive use of cyprohepatdine (5-HT2 antagonist)
What are the 8 signs of delirium?
DELIRIUM D - disordered thinking - slow irrational, jumbled up E - euphoric, fearful, depressed, angry L - language impaired I - illusions/delusions/hallucinations R - reversal of sleep-awake cycle I - inattention U - unaware/disorientated M - memory deficits
What can cause delirium?
Systemic infection - UTI/pneumonia
Intracranial infection - encephalitis/meningitis
Drugs - opiates/sedatives
Alcohol withdrawal
Metabolic - uraemia/liver failure
Hypoxia - resp/cardiac failure
Vascular - stroke/MI
Head injury - raised ICP/space occupying lesions
Epilepsy - non-convulsive status epilepticus/post ictal states
Nutritional - thiamine/nicotinic acid
How do you manage delirium?
Reduce distress
Moderately lit, quiet room with same staff
No physical restraints
Music, massage, muscle relaxation
If disruptive use sedation but minimise usage
Treat underlying cause
What is lithium toxicity?
Too much lithium > 1.5 mmol/L
Low risk of death
What are the symptoms of lithium toxicity - mild - moderate?
Diarrhoea N&V Stomach pains Fatigue Coarse tremor Uncontrollable movements Muscle weakness Drowsiness Excessive sleeping Weakness
What are the symptoms of lithium toxicity - severe?
Heightened reflexes Seizures Agitation Ataxia Kidney failure Tachycardia Hypotension Confusion Coma Death Delirium Myoclonic jerks
What are the causes of lithium toxicity?
Increased dose
Being dehydrated - fluid depletion, changes in salt level in diet, reduced renal function
Interactions - too low/high salt intake, too low/high caffeine, alcohol
Drug interactions - NSAIDs, indomethacin, COX2 inhibitors, acetaminophen, metronidazole, CCBs, ACEis, diuretics
Kidney problems
Change in lithium brand
How do you diagnose lithium toxicity?
ECG
Bloods - metabolism, electrolytes, lithium levels, U&Es
Urine for lithium levels
How do you manage lithium toxicity?
Mild - goes away on its own when you stop taking lithium and drink more Moderate to severe - Stop lithium - Stomach pumping if within last hour - Whole bowel irrigation - IV fluid rehydration - Haemodialysis - Medication - anticonvulsants - Vital sign monitoring
What is delirium?
A medical emergency
Transient acute syndrome, characterised by disturbances of consciousness, perception, sleep-wake cycle, emotion, and cognition
What is delirium a risk factor for?
Dementia
Institutionalisation
Death
What are the types of delirium?
Hypoactive - tired and sleepy
Hyperactive - delusions, thought disordered, reversed sleep-wake cycle
Mixed
What does the PINCH ME mnemonic stand for and what is it used for?
Causes of delirium Pain INfection Constipation deHydration Metabolic/medication Environment
What is the recover time for delirium?
Can take up to 3-6 months
What is catatonia?
Neuropsychiatric behavioural syndrome that is characterised by abnormal movements, immobility, abnormal behaviours, and withdrawal
Onset can be acute, or subtle, and symptoms can wax, wane or change during episodes
How can you diagnosed someone with catatonia?
If have any three of these signs
- Not responding to other people or their environment
- Not speaking
- Holding their body in an unusual position
- Resisting people who try to adjust their body
- Agitation
- Repetitive, seemingly meaningless movement
- Mimicking someone else’s movements or speech
What are the types of catatonia?
Akinetic
- Stares blankly and won’t respond when you speak to them
- If they do, they will only repeat what you said
- Sometimes sit or lie in an unusual position and won’t move
- Most common type
Excited
- Person may move around but movement seems pointless and impulsive
- Agitated, combative, delirious
- Mimicking movements of someone who’s trying to help them
Malignant
- Symptoms lead to other health problems like dangerous changes in BP, body temperature, or breathing or HR
- Someone who’s catatonic for a long time may be more likely to have problems like dehydration, blood cots, or kidney failure as a results of symptoms
What are the causes of catatonia?
Conditions that affect body chemistry like kidney problems, diabetes, thyroid conditions Parkinson's Encephalitis Mood disorders - depression and bipolar Psychosis
How do you treat catatonia?
Benzodiazepines
ECT
When is ECT recommended as a treatment of catatonia?
Sedative not working
Severe
Has had it before
Quick action required to save life
What is acute dystonic reaction?
Characterised by involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, larynx in either sustained or intermittent patterns leading to abnormal movements or postures
Neurological movement disorder characterised by continuous or intermittent muscle contractions which cause abnormal, often painful, repetitive movements
What can cause acute dystonic reaction?
S/E of
- Dopamine receptor antagonists eg haloperidol
- Anti-depressants
- Calcium antagonists
- Anaesthetic agents
- Anti-convulsants eg carbamazepine and phenytoin
- Illicit drugs - cocaine and ecstasy
What are the symptoms of acute dystonic reaction?
Strange movements of face and/or mouth Tongue protrusion Head tilts back Forced opening of mouth Problems eating or swallowing Eyes turned upwards or to the side Hyper-extension of the spine
How do you treat acute dystonic reaction?
Controlled withdrawal of medication causing the problem
Oral medications
Botulinum toxin injections
Deep brain stimulation
What is neuroleptic malignant syndrome?
Life-threatening idiosyncratic reaction to antipsychotic drugs characterised by fever, altered mental status, muscle rigidity, and autonomic dysfunction
What are the symptoms of neuroleptic malignant syndrome?
Very high fever Irregular pulse Tachycardia Tachypnoea Muscle rigidity Altered mental status Autonomic nervous system dysfunction resulting in hyper/hypotension Profuse perspiration Liver/kidney failure Hyperkalaemia Rhabdomyolysis Blood clots in veins and arteries
What are the causes of neuroleptic malignant syndrome?
Dopamine D2 receptor antagonism
When dopamine receptors in the hypothalamus or nigrostriatal pathways and spinal cord are blocked - leads to increased muscle rigidity
What are the differential diagnoses of neuroleptic malignant syndrome?
Anaphylaxis Malignant catatonia Heat stroke Malignant hyperthermia Serotonin syndrome
How do you treat neuroleptic malignant syndrome?
Withdrawal of medications
Restore appropriate water and nutrient levels
Lower body temperature
Medications for skeletal muscle relaxation
ECT
