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Psychiatry > Psychiatric emergencies > Flashcards

Psychiatric emergencies Flashcards

1
Q

Why is alcohol a depressant?

A

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

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2
Q

What are the symptoms of alcohol withdrawal?

A 
Pronounced tremor - can become a seizure and kill
Sweating
Vomiting
Activation syndrome
Seizures
Hallucinations
Delirium tremens
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3
Q

What are the symptoms of activation syndrome?

A

Tremors
Agitation
Rapid HR
Decreased BP

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4
Q

How do you treat alcohol withdrawal?

A

Medication - acamprostate calcium, disulfiram, nalmefene, naltexone, chlordiazepoxide, diazepam
Psychosocial - therapy, social support

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5
Q

What is delirium tremens?

A

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

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6
Q

When does delirium tremens occur?

A

3 days into withdrawal symptoms and may last 2-3 days

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7
Q

What are the symptoms of delirium tremens?

A 
Tremors 
Agitation
Confusion/disorientation
Hallucinations
Sensitivity to light and sounds
Seizures
Fever
Tachycardia
Hypertension
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8
Q

How do you manage delirium tremens?

A 
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
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9
Q

What is Wernicke’s encephalopathy?

A

Thiamine deficiency in severely dependent drinkers
Leads to focal areas of brain damage
Death of mammillary bodies

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10
Q

Why do dependent drinkers develop encephalopathy?

A

Poor diet/intake of vitamins
Poor GI absorption
High demand as metabolism of alcohol depends on thiamine as co-enzyme

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11
Q

What is the role of thiamine in the brain?

A

Involved in lipid (myelin sheath) and carbohydrate metabolism, production of amino acids and production of glucose derived neurotransmitters

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12
Q

What is the complication of Wernicke’s encephalopathy?

A

Korsakoff’s syndrome

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13
Q

What is Korsakoff’s syndrome?

A

Hypothalamic damage due to thiamine deficiency

Decreased ability to acquire new memories, confabulation, lack of insight and apathy

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14
Q

What are the symptoms of Wernicke’s encephalopathy?

A 
Confusion
Ataxia
Ophthalmoplegia (nystagmus, lateral rectus/conjugate nerve palsies)
Hypotension
Hypothermia
Reduced consciousness
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15
Q

How is Wernicke’s encephalopathy treated?

A

Urgent thiamine

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16
Q

What is serotonin syndrome?

A

Toxic syndrome of too much serotonin in the brain

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17
Q

What is the triad of symptoms of serotonin syndrome?

A

Neuromuscular abnormalities
Altered mental state
Autonomic dysfunction

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18
Q

What can cause serotonin syndrome?

A

Co-administration of anti-depressants
Often occurs with SSRI/SNRI with other medication raising serotonin level
St John’s wort

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19
Q

What are the symptoms of serotonin syndrome?

A 
Confusion
Agitation
Muscle twitching
Sweating
Shivering
Diarrhoea
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20
Q

How do you treat serotonin syndrome?

A

Depends on presentation

Ranges from supportive use of cyprohepatdine (5-HT2 antagonist)

21
Q

What are the 8 signs of delirium?

A 
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
22
Q

What can cause delirium?

A

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

23
Q

How do you manage delirium?

A

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

24
Q

What is lithium toxicity?

A

Too much lithium > 1.5 mmol/L

Low risk of death

25
Q

What are the symptoms of lithium toxicity - mild - moderate?

A 
Diarrhoea
N&V
Stomach pains
Fatigue
Coarse tremor
Uncontrollable movements
Muscle weakness
Drowsiness
Excessive sleeping
Weakness
26
Q

What are the symptoms of lithium toxicity - severe?

A 
Heightened reflexes
Seizures
Agitation
Ataxia
Kidney failure
Tachycardia
Hypotension
Confusion
Coma
Death
Delirium
Myoclonic jerks
27
Q

What are the causes of lithium toxicity?

A

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

28
Q

How do you diagnose lithium toxicity?

A

ECG
Bloods - metabolism, electrolytes, lithium levels, U&Es
Urine for lithium levels

29
Q

How do you manage lithium toxicity?

A 
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
30
Q

What is delirium?

A

A medical emergency
Transient acute syndrome, characterised by disturbances of consciousness, perception, sleep-wake cycle, emotion, and cognition

31
Q

What is delirium a risk factor for?

A

Dementia
Institutionalisation
Death

32
Q

What are the types of delirium?

A

Hypoactive - tired and sleepy
Hyperactive - delusions, thought disordered, reversed sleep-wake cycle
Mixed

33
Q

What does the PINCH ME mnemonic stand for and what is it used for?

A 
Causes of delirium
Pain
INfection
Constipation
deHydration
Metabolic/medication
Environment
34
Q

What is the recover time for delirium?

A

Can take up to 3-6 months

35
Q

What is catatonia?

A

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

36
Q

How can you diagnosed someone with catatonia?

A

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
37
Q

What are the types of catatonia?

A

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

38
Q

What are the causes of catatonia?

A 
Conditions that affect body chemistry like kidney problems, diabetes, thyroid conditions
Parkinson's
Encephalitis
Mood disorders - depression and bipolar
Psychosis
39
Q

How do you treat catatonia?

A

Benzodiazepines

ECT

40
Q

When is ECT recommended as a treatment of catatonia?

A

Sedative not working
Severe
Has had it before
Quick action required to save life

41
Q

What is acute dystonic reaction?

A

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

42
Q

What can cause acute dystonic reaction?

A

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
43
Q

What are the symptoms of acute dystonic reaction?

A 
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
44
Q

How do you treat acute dystonic reaction?

A

Controlled withdrawal of medication causing the problem
Oral medications
Botulinum toxin injections
Deep brain stimulation

45
Q

What is neuroleptic malignant syndrome?

A

Life-threatening idiosyncratic reaction to antipsychotic drugs characterised by fever, altered mental status, muscle rigidity, and autonomic dysfunction

46
Q

What are the symptoms of neuroleptic malignant syndrome?

A 
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
47
Q

What are the causes of neuroleptic malignant syndrome?

A

Dopamine D2 receptor antagonism
When dopamine receptors in the hypothalamus or nigrostriatal pathways and spinal cord are blocked - leads to increased muscle rigidity

48
Q

What are the differential diagnoses of neuroleptic malignant syndrome?

A 
Anaphylaxis
Malignant catatonia
Heat stroke
Malignant hyperthermia
Serotonin syndrome
49
Q

How do you treat neuroleptic malignant syndrome?

A

Withdrawal of medications
Restore appropriate water and nutrient levels
Lower body temperature
Medications for skeletal muscle relaxation
ECT

Psychiatry (15 decks)

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