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Psychiatric emergency | Flashcards

1
Q

What is a psychiatric emergency?

A

Any disturbance in thought, feeling or actions for which immediate therapeutic intervention is necessary

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2
Q

What are 3 classes of psychiatric emergencies?

A
  1. Major
  2. Minor
  3. Medical emergencies in psychiatry
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3
Q

What are the major psychiatric emergencies (2)?

A
  1. Suicidal patients

2. Agitated & violent patients

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4
Q

What are minor psychiatric emergencies (4)?

A
  1. Grief reaction
  2. Rape
  3. Disaster
  4. Panic attacks
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5
Q

What are medical emergencies in psychiatry (5)?

A
  1. Delirium
  2. Neuroleptic Malignant Syndrome
  3. Serotonin syndrome
  4. Overdose of common psychiatric medications
  5. Overdose & withdraw from addicting substance
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6
Q

What time of day do psychiatric emergencies peak?

A

Between 6 and 10 pm when there is more tendency to have conflicts when family members are home together, substance use increases and aggravates aggressive behaviour. During this time it is difficult to access counsellors, GPs and other resources

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7
Q

What is delirium?

A

A transient, potentially reversible cerebral dysfunction that has an acute or sub- acute onset which is manifested clinically by a wide range of fluctuating mental status abnormalities.
Delirium is common and can be potentially lethal

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8
Q

What is the epidemiology of delirium?

A
  1. Delirium is very common in all health care setting but in the hospital, it has a point prevalence of 10-30%.
  2. 10-15% of the elderly population have delirium on admission to acute hospital and a further 10-40% develop delirium during their stay.
  3. In up to two-thirds of delirium is superimposed on dementia.
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9
Q

What is the ICD-10 criteria for delirium (4)?

A
  1. Clouding of consciousness, i.e. reduced clarity of awareness of environment, with reduced ability to focus, sustain or shift attention
  2. Disturbed cognition, with impaired immediate recall and recent memory but relatively intact remote recall, and disorientation in time, place or person
  3. At least one of the followings:
    - variable activity levels, increased reaction time, altered flow of speech or enhanced startle reaction
  4. At least another one of the followings:
    - insomnia, daytime drowsiness, reversal of sleep–wake cycle, nocturnal worsening of symptoms or disturbing dreams and nightmares
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10
Q

What is the onset and course of delirium?

A

Abrupt onset and fluctuating course are typical and highly suggestive of delirium.

It is characterised by significant disturbances in attention along with associated deficits in memory and orientation, disorganised thinking and perceptual disturbances.

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11
Q

What are 5 types of delirium?

A
  1. Hyperactive delirium: a subtype of delirium characterised by people who have heightened arousal and can be restless, agitated or aggressive.
  2. Hypoactive delirium: a subtype of delirium characterised by people who become withdrawn, quiet and sleepy.
  3. Mixed delirium
  4. Delirium superimposed on Dementia
  5. Persistent delirium
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12
Q

What is the assessment of delirium?

A
  1. Take a history - you may need informant, as well as history from the records
  2. Consider physical causes for e.g. infection, constipation, dehydration, medication induced, alcohol withdrawal etc. (see next slide): Need physical examination & investigations
  3. Risk assessment (to self and to others)
  4. Complete a baseline cognitive examination: some tools which can be useful include -
    a. Abbreviated Mental Test (AMT)
    b. Montreal-Cognitive Assessment (MoCA)
    c. Mini-mental state examination (MMSE)
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13
Q

What investigations do you do for delirium (5)?

A
  1. Infection: cultures, urinalysis, full blood count, C-reactive Protein(CRP), Chest X-ray, etc
  2. Medications: Review all medications
  3. Metabolic/endocrine: Urea and electrolytes, Liver function tests, calcium, glucose, thyroid function tests
  4. Others:
    - Cardiac: ECG
    - Hypoxia: O2 saturation
  5. Neurological: CT/MRI Brain
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14
Q

What is the management of delirium?

A
  1. Identify and treat the precipitating cause
  2. Provide a calm environment and supportive measures (see next tab)
  3. Involve family and carer
  4. Consider referral to psychiatric team (especially if there is a history of mental health issues, suspected dementia, suspected depression, persistent delirium, aggression, controversial capacity or considering Mental health Act)
  5. Avoid sedation unless severely agitated
  6. Review patient regularly
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15
Q

What are environment and supportive measures of management of delirium (12)?

A
  1. Education off all who interact with patients (doctors, nurses, family etc)
  2. Reality orientation techniques – improve communication by use of calender, clock
  3. Correct sensory impairments (e.g. hearing aids, glasses)
  4. Optimize patients condition - attention to hydration, nutrition, adequate pain control
  5. Create an environment that optimises stimulation (e.g. adequate lighting), reduce unnecessary noise
  6. Make environment safe (remove objects with which patients could harm self or others)
  7. Avoid moving people between wards or rooms
  8. Maintain hydration and oxygenation
  9. Avoid constipation
  10. Avoid unnecessary catheterisation
  11. Maintain good sleep pattern
  12. Assess and manage pain
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16
Q

What are possible causes of delirium?

A

I WATCH DEATH

I Infection: HIV, sepsis, pneumonia

W Withdrawal: Alcohol, barbiturate, sedative e.g. hypnotic
A Acute metabolic: Acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure
T Trauma : Closed-head injury, heat stroke, postoperative, severe burns
C CNS pathology: Abscess, haemorrhage, hydrocephalus, subdural hematoma, Infection, seizures, stroke, tumours, metastases, vasculitis, encephalitis, meningitis, syphilis
H Hypoxia: anaemia, carbon monoxide poisoning, hypotension, pulmonary or cardiac failure

D Deficiencies: Vitamin B12, folate, niacin, thiamine
E Endocrinopathies: Hyper/hypoadrenocorticism, hyper/hypoglycemia, myxedema, hyperparathyroidism
A Acute vascular: Hypertensive encephalopathy, stroke, arrhythmia, shock
T Toxins or drugs: Prescription drugs, illicit drugs, pesticides, solvents
H Heavy Metals: Lead, manganese, mercury.

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17
Q

What are causes of acute behavioural disturbance?

A

Acute behavioural disturbances can develop in people suffering from mental health issues at any time during the course of their mental illness or can be a manifestation of underlying systemic organic illness (eg infection).

Patients can become agitated or aggressive during an acute episode of illness such as mania or schizophrenia:

  • Maybe directly due to psychotic symptoms such as delusion or hallucinations
  • Due to non-psychotic symptoms such as high levels of anxiety or arousal
  • Use of illicit substances such as cannabis, amphetamines
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18
Q

What are the 3 important basic principles of management of acute behavioural disturbance?

A
  1. Predictions of risk of agitation
  2. Prevention of behaviour escalating once patients begins disturbed
  3. Use of interventions to ensure safety of the patients and staff
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19
Q

What are 5 things you may need to consider when managing someone with acute behavioural disturbance?

A
  1. The need for admission, including the use of Mental Health Act or Mental Capacity Act
  2. The level of security needed - does police need to be involved? e.g. if threatened or actual violence persists despite adequate attempts to manage the situation
  3. The level of observation required to manage patient effectively
  4. The need for medication
  5. The need for physical restraint
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20
Q

What specific qs should you ask about history of PC in people with acute behavioural disturbance (2)?

A
  1. List current problems and their precipitants

2. Why are they presenting now?

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21
Q

What specific qs should you ask about past psychiatric history in people with acute behavioural disturbance (4)?

A
  1. Is the current presentation similar to previous presentations?
  2. What treatment helped before?
  3. History of self-harm
  4. History of violence
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22
Q

What specific qs should you ask about medical history in people with acute behavioural disturbance (4)?

A
  1. Is there a medical problem which could explain the presentation?
  2. Is there a medical contraindication to your proposed treatment?
  3. Would drug side-effects/toxicity explain the presentation?
  4. Poor compliance with treatment
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23
Q

What specific qs should you ask about family history in people with acute behavioural disturbance (2)?

A
  1. Does family history provide a clue to diagnosis?

2. Family history of mental illness

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24
Q

What specific qs should you ask about personal history in people with acute behavioural disturbance (1)?

A

Identify previous crises and how they were dealt with

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25
Q

What specific qs should you ask about social history in people with acute behavioural disturbance (2)?

A
  1. Recent change in social circumstances?

2. Issues employment , relationships, benefits etc

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26
Q

What specific qs should you ask about drug and alcohol history in people with acute behavioural disturbance (1)?

A

Use of alcohol and illicit drug use

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27
Q

What specific qs should you ask about forensic history in people with acute behavioural disturbance (2)?

A
  1. Previous charges , convictions

2. Access to weapons

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28
Q

What specific qs should you ask about premorbid personality in people with acute behavioural disturbance (1)?

A

How patient coped with previous stressors

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29
Q

What are 6 signs in the mental state that could indicate increase risk of aggression with acute behavioural disturbance (6)?

A
  1. Persecutory delusions
  2. Delusions of passivity
  3. Actual threats of violence
  4. Emotional states linked to violence (e.g. irritability, hostility, sense of grievance, shouting or talking loudly)
  5. Behaviour (e.g. pacing, refusing to sit down, invading personal space)
  6. Limited insight
30
Q

What are some warning signs that could indicate violent behaviours in acute behavioural disturbance?

A
  1. Angry facial expression
  2. Restless or pacing
  3. Shouting
  4. Pronged direct eye contact
  5. Refusal to cooperate
  6. Presence of delusions or hallucination with violent content
  7. Verbal threats or reports thoughts of violence
  8. Blocking escape routes
  9. Evidence of arousal (sympathetic nervous system activation)
31
Q

What are some factors to consider in the assessment of the need for urgent treatment and/or admission?

A
  1. Severity of illness
  2. Ability to care for self (is there evidence of neglect or emaciation?)
  3. Risk of self-harm
  4. Risk of harming others
  5. What other supports are available?
  6. The level of insight? (If insight is poor and the person is not admitted, contact may be lost)
  7. Age (the very old may be vulnerable)
  8. Need for supervision (e.g. with medication)
  9. Need to clarify diagnosis/severity of illness
32
Q

What is the aim of de-escalation?

A

The aim is to predict the possible violence and to de-escalate the situation as soon as possible

33
Q

What are the principles of de-escalation?

A
  1. Most situations respond to such measures and it should be the first step in managing acute behavioural disturbance.
    - Physical restraint and medications only used when these measures fail or are inappropriate
  2. One member of staff should be in charge and carry out the following:
    - Encourage patient to move into a separate room or area which is away from other patients or visitors
    - Speak confidently, slowly, clearly without making too much variation in the tone or volume of the voice
    - Adopt a non–threatening body posture: reduce prolonged direct eye contact, keep your both hands visible and make slow movements
    - Use non-threatening verbal communication
    - Pre-warn the patients e.g. “I am going to move towards the door”
    - Explore concerns with the patient: ask them to explain if they have any problems, how are they feeling and why the situation is happening.
  3. If possible, try to develop a rapport with the patient: try to engage them in a conversation, show empathy and concern. If they have any issues offer solutions to any problems.
  4. If you suspect weapons with the patient, make sure that there are minimum number of people in the room and request patient to put the weapon down in a neutral position
34
Q

When 1st line non-pharmacological techniques fail, what other techniques can be used to manage acute behavioural disturbance?

A
  1. Medications for rapid tranquilisation (RT)
  2. Physical restraint
  3. Seclusion
35
Q

What is the aim of rapid tranquilisation in acute behavioural disturbance?

A

To calm the agitated patient without sedating them and to reduce the risk of violence and harm

36
Q

What medications can be used for RT in acute behavioural disturbance?

A
  1. Benzodiazepines
  2. Antipsychotics
  3. Combination of the above
  4. Promethazine
37
Q

What are the routes of administration of RT in acute behavioural disturbance?

A
  1. Whenever possible medications should be given orally
  2. However, sometimes it becomes necessary to administer medications by intramuscular injection while patient is being sedated
38
Q

What are 3 things to consider when administrating an RT for acute behavioural disturbance?

A
  1. Always consult a senior doctor before as it can be a hazardouse route, especially in an agitated patient
  2. Use the minimum dose of the medications
  3. When prescribing medications, choose the one with rapid onset, short acting, minimal side effects and easily reversible effects
39
Q

What are the choice of benzodiazepines for RT?

Which ones are usually used for RT and why?

A
  1. Lorazepam - widely used for RT
    - It has a quick onset of action, a shorter duration of action and relatively safe and tolerable
  2. Midazolam
    - Onset of action within 15 minutes after intramuscular use, and within 3-5 minutes after intravenous use
  3. Diazepam
    - Longer half-life and if it is given Intramuscularly has an erratic and slow absorption
40
Q

What antipsychotics are used in RT?

Why are they used?

A
  1. Haloperidol - commonest medication that is used
  2. Olanzapine can also be used

Can reduce agittion

41
Q

What are some important considerations of using sedatives in managing acute behavioural disturbance?

A
  1. Drawback is that patient might become drowsy and may not be suitable for further psychiatric assessment under the Mental Health Act
  2. Always ensure cardiopulmonary resuscitation facilities are available as these medications can cause cardiopulmonary arrest!!!
  3. It is important to carry out appropriate physical observation after administering medications such as records of pulse rate, blood pressure, temperature, respiratory rate and oxygen saturation
  4. If possible always do ECG before administering haloperidol
  5. If medication in administered intramuscularly:
    - Maintain dignity for the patient.
    - Every effort should be made to ensure that the staff administering the medication is of the same gender as the patient receiving the medication
    - Ensure privacy away from other patients
42
Q

What are 5 possible complications of RT?

A
  1. Acute dystonia
  2. Hypotension
  3. Neuroleptic malignant syndrome (NMS)
  4. Respiratory depression
  5. Arrhythmias
43
Q

What are signs/symptoms of hypotension?

How do you manage it?

A

Fall in blood pressure (orthostatic or <50mmHg diastolic

Lie patient flat & raise legs; Monitor closely

44
Q

What are signs/symptoms of respiratory depression?

How do you manage it?

A

Reducing consciousness and respiratory rate

Give O2 ,raise legs; If RR < 10 in patient with benzodiazepines: Give Flumazenil 200microgram IV over 15 seconds

45
Q

What are signs/symptoms of arrhytmias?

How do you manage it?

A

Irregular pulse or pulse rate< 50/min

Monitor closely
Liaise with medical team

46
Q

What is neuroleptic malignant syndrome (NMS)?

What is it caused by?

A

Rare, but potentially serious and fatal adverse effect of all anti-psychotic medication

It is due to dopamine blockade leading to sympathetic hyperactivity

47
Q

What are risk factors for NMS (4)?

A
  1. History: previous NMS, known cerebral compromise or organic brain damage, alcoholism
  2. Mental state: agitation, over activity, catatonia
  3. Physical state: dehydration
  4. Treatment-related factors: intramuscular therapy; recent or rapid antipsychotic medication dose increase; rapid dose reduction/abrupt withdrawal of anticholinergic medication; high doses of antipsychotic medications; high potency neuroleptic medication like haloperidol
48
Q

What are symptoms of NMS (6)?

A

Varied presentation

  1. fever
  2. diaphoresis
  3. rigidity
  4. confusion
  5. fluctuating consciousness
  6. Autonomic instability:
    - fluctuating blood pressure
    - tachycardia
    - diaphoresis
    - salivation
    - incontinence
49
Q

What are investigations done for NMS?

A
  1. There are no blood tests which are pathognomonic of NMS
  2. Creatinine kinase (CK) is frequently raised and often exceeds 1000units/litre
  3. Patients can also have leucocytosis
  4. May have deranged liver function tests
50
Q

What is the management of NMS?

A
  1. Withdraw antipsychotic medication
  2. Monitor temperature, blood pressure and pulse
  3. Consider benzodiazepine for sedation
  4. Rehydration
  5. Dopamine agonist like Bromocriptine or dantrolene may be used
  6. Always consult a psychiatrist before starting any antipsychotic medication in any patients who might have had NMS
51
Q

What is acute dystonia?

A

Reversible extrapyramidal side effects that occur after administration of antipsychotic mediations

It is a muscle spasm occurring anywhere in the body

Can be lie-threatening if it includes laryngeal muscles

52
Q

How do medications cause acute dystonia?

A

Most medications cause dystonic reactions by Dopamine D2 receptor blockade in nigrostriatal pathway which leads to an excess of striatal cholinergic output

53
Q

What is the prevalence of acute dystonia?

A

10%

54
Q

What are risk factors for acute dystonia (3)?

A
  1. Male
  2. Those who are neuroleptic naive
  3. With high potency dopamine receptor D2 blocker such as Haloperidol

Rare in elderly

55
Q

What are symptoms of acute dystonia?

A
  1. Symptoms can begin immediately or can be delayed for few hours to days
  2. Characterised by intermittent spasmodic or sustained involuntary contractions of muscles of face, neck, trunk, pelvis, extremities and even larynx (any muscle group)
  3. Frequency of occurence of dystonia:
    - Torticollis 30%
    - Tongue (17%)
    - Jaw (15%)
    - Oculogyric crisis (neck arched and eye rolled back) (6%)
56
Q

What is the treatment of acute dystonia?

A
  1. Anticholinergic medications:
    Procyclidine 5-10mg IM/IV or
    Benzotropine 1-2mg
  2. Remember that patient may be unable to swallow
  3. With IM administration, response is seen around 20 minutes and within 5 minutes with IV administration
  4. Check for cyanosis and administer oxygen and transfer to a medical unit as required​
57
Q

What is the only route of administration of lithium and how is it excreted?

A

Orally

Excreted by kidneys

58
Q

What are important things to check for in a patient on lithium and why?

A
  1. Renal function
    - Lithium excreted by kidneys so clearance reduced in renal impairment
  2. Check blood levels regularly - initially weekly thereafter once in every 3 months
    - Narrow therapeutic range
59
Q

What are the upper limit levels of lithium within the therapeutic range at 12 hours after last dose?

A

Upper limit: 1.2mmol/l

60
Q

How long after the last dose of lithium is given do you check blood levels?

A

12 hours

61
Q

At what level of lithium do patients experience toxicity?

At what level of lithium do life-threatening toxic effects occur?

A
  1. 5 mmol/l

2. 0 mmol/l

62
Q

What medications increase serum levels of lithium, and therefore should be avoided?

A
  1. Diuretics (especially thiazides)
  2. NSAIDs
  3. ACEI
63
Q

What are 5 early symptoms and 6 later symptoms of lithium toxicity?

A

Onset can be slow (days-weeks)

Early

  1. Marked tremor
  2. Anorexia
  3. Nausea/vomiting
  4. Diarrhoea
  5. Dehydration & lethargy

Late - neurological complications

  1. Restlessness
  2. Muscle fasciculations
  3. Myoclonic jerks
  4. Choreo-athetoid movements
  5. Marked hypertonicity
  6. This may progress to ataxia, dysarthria, increased lethargy, drowsiness, confusion, hypotension, arrhythmias, emerging seizures, stupor and coma
64
Q

What is the treatment of lithium toxicity (4)?

A
  1. Prevention - education of patients to maintain adequate hydration and salt intake
  2. If you suspect Lithium toxicity, immediately stop lithium
  3. Maintain adequate hydration
  4. In severe toxicity: patient may require forced diuresis or haemodialysis
65
Q

What do you need to be aware of when prescribing lithium?

A

It can have potentially life-threatening serious interactions with other medications. Before prescribing any medications always check British National Formulary for any interactions.

66
Q

What is serotonin syndrome (SS)?

A

A rare but potentially life-threatening condition occurring in the context of initiation or dose increase of a serotonergic medication

67
Q

What are the 2 commonest causes of SS in clinical practice?

What is a less common cause?

A

When patients are being:

  1. Switched over from one antidepressant medication to another
  2. When a combination of antidepressants is used
  3. Can also occur if patients are taking antidepressants medications and taken other medications and supplements such as Triptans for a migraine, herbal supplements like St. John’s wort or illegal substances like LSD, Cocaine, amphetamines etc
68
Q

What are symptoms of SS?

  1. Psychiatric (3)
  2. Autonomic (5)
  3. Neuromuscular (6)
A

Manifestation of SS highly variable and can present within a few hours after taking new medications that can increase serotonin activity in CNS

  1. Psychiatric
    - Restlessness
    - Confusion
    - Agitation
  2. Autonomic
    - Hyperthermia (could be related to prolonged seizure activity, rigidity or muscular hyperactivity)
    - GI upset
    - Tachycardia
    - Hypo or hypertension
    - Mydriasis
  3. Neuromuscular
    - Myoclonus
    - Rigidity
    - Tremors
    - Hyperreflexia
    - Ataxia
    - Convulsions
69
Q

What is the treatment of SS (5)?

A
  1. Stop the medication which might be the precipitating cause
  2. Symptomatic treatment with rehydration
  3. Benzodiazepines can be used for agitation.
  4. If symptoms are severe transfer immediately to the emergency department.
  5. If overdose – consider gastric lavage
70
Q

What are the differences between NMS and SS according to:

  1. Associated treatment
  2. Onset
  3. Progression
  4. Muscle rigidity
  5. Activity
A

NMS

  1. Antipsychotics (idiosyncratic or normal dose)
  2. Slow (days to weeks)
  3. Slow (24-72 hours)
  4. Severe (lead pipe)
  5. Bradykinesia

SS

  1. Serotonergic medications (overdose or combinations)
  2. Rapid
  3. Rapid
  4. Less severe
  5. Hyperkinesia

Psychiatry (16 decks)

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