Psychiatric Emergency

Question 1

What is neuroleptic malignant syndrome

Answer 1

rare, but serious and potentially fatal effect of antipsychotics

Dopamine receptor blockage resulting in sympathetic hyperactivity

Question 2

how many people on antipsychotics experience neuroleptic malignant syndrome

Answer 2

<1%

Question 3

what are risk factors for neuroleptic malignant syndrome

Answer 3

Previous history 
known organic brain damage
alcoholism 
catatonia
agitation
dehydration
IM therapy
rapid/recent medication increase
rapid dose reduction/abrupt withdrawal of anticholinergic medication 
high dose antipsychotic 
use of haloperidol

Question 4

what is the general presentation of neuroleptic malignant syndrome

Answer 4

slow onset, slowly progressive:

fever
diaphoresis
rigidity (KEY SYMPTOM) 
confusion 
fluctuating BP 
tachycardia
incontinence
salivation

Question 5

what tests can you do for neuroleptic malignant syndrome

Answer 5

no definitive test

CK is often elevated, LFTs derranged and leucocytosis is present

vital signs are alsooften severely derranged

Question 6

what is the treatment for neuroleptic malignant syndrome

Answer 6

withdrawal of antipsychotic and supportive therapy (fluids/cooling/feeding)

lorazepam to help with muscle rigidity

dantroline/amantidine/bromocriptine as secondary medications

Question 7

what is acute dystonia

Answer 7

extrapyramidal side effects of typical antipsychotics, causing idiosyncratic, unpredictable muscle spasms that may occur anywehere

Question 8

what is the neuropharmacology behind acute dystonia

Answer 8

dopamine receptor blockade in the nigrostriatal pathway leads to an increase in striatal cholinergic output

Question 9

what antipsychotic is most likely to cause dystonia

Answer 9

haloperidol

Question 10

whats the prevalence of acute dystonia in people taking antipsychotics

Answer 10

10%

Question 11

what increases the risk of acute dystonia occurring

Answer 11

young men
high potency D2-receptors
neuroleptic naive patients (first neuroleptic medication)

Question 12

what body parts are most frequently affected by acute dystonia and by what %

Answer 12

neck 30%
tongue 17%
jaw 15%
neck arch, eye roll back 6%

Question 13

by what means is lithium excreted

Answer 13

kidneys

Question 14

what is important to establish before starting lithium treatment

Answer 14

U+E and GFR

Question 15

what are some early symptoms of lithium overdose

Answer 15

tremor
anorexia (not hungry) 
n+v
diarrhoea
dehydration

Question 16

what are some late symptoms of lithium overdose

Answer 16

restlessness
muscle fasciculations
myoclonic jerks 
choero-arterioid movements 
marked hypertonicity 
progression to ataxia, lethargy, dysarthria, drowsiness, arrythmia, stupor and coma

Question 17

what is seratonin syndrome

Answer 17

a rare but potentially life-threatening condition occurring in the context of initiation or dose increase of a serotonergic medication (e.g. SSRI)

Question 18

how do you treat lithium toxicity

Answer 18

mild: admit + observe (should go away on own)

moderate-severe: stomach pump/bowel irrigation/iv fluids/haemodialysis/anticonvulsants if seizing

Question 19

when is seratonin syndrome most common

Answer 19

when switching SSRIs or when someone is placed on multiple seratonergic medications

Question 20

what OTC meds may cause seratonin syndrome in patients already taking

Answer 20

St Johns wort, triptans, LSD (not OTC but same vibe)

Question 21

what are some symptoms of seratonin syndromes

Answer 21

Psychiatric - confusion, agitation, restlessness

Autonomic - hyperthermia GI upset, tachycardia, hypo/hypertension, mydriasis

Neuromuscular - myoclonus, rigidity, tremors, hyperreflexia, ataxia, convulsaions

Question 22

How quickly does serotonin syndrome come on

Answer 22

very quickly, over a few hours

Question 23

what is the progression of serotonin syndrome like

Answer 23

rapid

Question 24

How do you manage an acute behavioural disturbance

Answer 24

depends on the risk of agitation/aggression

seriously consider admission if you feel it is required

avoid sedation unless absolutely necessary

Question 25

if someone is acutely disturbed, what MSE signs indicate a higher risk of progression to violence

Answer 25

persecutory delusions
delusions of passivity (their actions are imposed by an external force)
violent threats
emotional states linked to violence
pacing, refusing to sit down, invading personal space
limited insight

Question 26

if required, what are the principles of pharmacological sedation of a disturbed patient

Answer 26

minimum dose by order of a senior doctor, rapid onset short 1/2 life desirable

Question 27

what are some sedative options

Answer 27

lorazepa,,
midazolap
diazepam - longer 1/2 life however
haloperidol 
olanzipine

Question 28

how is acute dystonia treated for

Answer 28

procyclidine or benzotropine

Question 29

how do you treat hypotension

Answer 29

lie flat and raise legs

Question 30

how do you treat respiratory depression

Answer 30

oxygen, raise legs

flumazenil 200micrograms IV

Question 31

how do you treat tardive dyskinesia

Answer 31

tetrabenzine

Question 32

how do you treat serotonin syndrome

Answer 32

stop medication

symptomatic treatment with rehydration