Psychiatric Emergency Flashcards
What is neuroleptic malignant syndrome
rare, but serious and potentially fatal effect of antipsychotics
Dopamine receptor blockage resulting in sympathetic hyperactivity
how many people on antipsychotics experience neuroleptic malignant syndrome
<1%
what are risk factors for neuroleptic malignant syndrome
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
what is the general presentation of neuroleptic malignant syndrome
slow onset, slowly progressive:
fever diaphoresis rigidity (KEY SYMPTOM) confusion fluctuating BP tachycardia incontinence salivation
what tests can you do for neuroleptic malignant syndrome
no definitive test
CK is often elevated, LFTs derranged and leucocytosis is present
vital signs are alsooften severely derranged
what is the treatment for neuroleptic malignant syndrome
withdrawal of antipsychotic and supportive therapy (fluids/cooling/feeding)
lorazepam to help with muscle rigidity
dantroline/amantidine/bromocriptine as secondary medications
what is acute dystonia
extrapyramidal side effects of typical antipsychotics, causing idiosyncratic, unpredictable muscle spasms that may occur anywehere
what is the neuropharmacology behind acute dystonia
dopamine receptor blockade in the nigrostriatal pathway leads to an increase in striatal cholinergic output
what antipsychotic is most likely to cause dystonia
haloperidol
whats the prevalence of acute dystonia in people taking antipsychotics
10%
what increases the risk of acute dystonia occurring
young men
high potency D2-receptors
neuroleptic naive patients (first neuroleptic medication)
what body parts are most frequently affected by acute dystonia and by what %
neck 30%
tongue 17%
jaw 15%
neck arch, eye roll back 6%
by what means is lithium excreted
kidneys
what is important to establish before starting lithium treatment
U+E and GFR
what are some early symptoms of lithium overdose
tremor anorexia (not hungry) n+v diarrhoea dehydration
what are some late symptoms of lithium overdose
restlessness muscle fasciculations myoclonic jerks choero-arterioid movements marked hypertonicity progression to ataxia, lethargy, dysarthria, drowsiness, arrythmia, stupor and coma
what is seratonin syndrome
a rare but potentially life-threatening condition occurring in the context of initiation or dose increase of a serotonergic medication (e.g. SSRI)
how do you treat lithium toxicity
mild: admit + observe (should go away on own)
moderate-severe: stomach pump/bowel irrigation/iv fluids/haemodialysis/anticonvulsants if seizing
when is seratonin syndrome most common
when switching SSRIs or when someone is placed on multiple seratonergic medications
what OTC meds may cause seratonin syndrome in patients already taking
St Johns wort, triptans, LSD (not OTC but same vibe)
what are some symptoms of seratonin syndromes
Psychiatric - confusion, agitation, restlessness
Autonomic - hyperthermia GI upset, tachycardia, hypo/hypertension, mydriasis
Neuromuscular - myoclonus, rigidity, tremors, hyperreflexia, ataxia, convulsaions
How quickly does serotonin syndrome come on
very quickly, over a few hours
what is the progression of serotonin syndrome like
rapid
How do you manage an acute behavioural disturbance
depends on the risk of agitation/aggression
seriously consider admission if you feel it is required
avoid sedation unless absolutely necessary
if someone is acutely disturbed, what MSE signs indicate a higher risk of progression to violence
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
if required, what are the principles of pharmacological sedation of a disturbed patient
minimum dose by order of a senior doctor, rapid onset short 1/2 life desirable
what are some sedative options
lorazepa,, midazolap diazepam - longer 1/2 life however haloperidol olanzipine
how is acute dystonia treated for
procyclidine or benzotropine
how do you treat hypotension
lie flat and raise legs
how do you treat respiratory depression
oxygen, raise legs
flumazenil 200micrograms IV
how do you treat tardive dyskinesia
tetrabenzine
how do you treat serotonin syndrome
stop medication
symptomatic treatment with rehydration
