Psychiatric Eval, Mgmt, DoA Flashcards
Describe common medical complaints that may be related to organic psychiatric illness?
- Palpitations
- Chest pain, tightness
- SOB
- Abd pain, N/V
- HA
- Syncope
- Seizures
- Paresthesia
- Throat tightness
- Tremors
- Fear/panic
Name several organic causes of psychaitric illness, and several inorganic causes
- Organic
- Drug toxicity/intox
- Withdrawal
- Head trauma
- Encephalopathy
- Hypoglycemia
- Metabolic/electrolyte derrangement
- Hypoxia
- Organ failure
- Postictal
- Hyper/hypothyroid
- Inorganic
- Primary psychiatric illness
- Depression, psychosis, anxiety/panic, bipolar, schizophrenia
- Behavioral disturbance
- Autism
- Dementia
- Cognitive disability
- Primary psychiatric illness
Name your red flags that a patient’s psychiatric illness has an organic root cause
- Rapid onset of new psych symptoms
- New onset > 40 years old
- Any onset > 65 years old
- Delirium present
- Focal neuro deficit
- Presence of toxidrome
- Traumatic injury/illness evident
- Abnormal vitals: Fever, tachycardia, hotn, hypoxia, tachypnea
- Visual vs auditory hallucinations
- Visual tend to be a/w delirium, whereas auditory tend to be a/w psychosis
What is your diagnostic workup for acute psychiatric illness?
What are your key pharmacologic considerations re: poisonings, adverse drug effects, and OTC meds?
- Dx workup
- None if inorganic/primary psychiatric
- Based on history and physical
- Rule out underlying medical causes that require tx
- Consider differentials beyond the psych symptom
- Poisonings
- Dilantin
- Digoxin
- TCAs
- ADEs
- Depakote
- Prednisone
- SSRI/SNRI in bipolar patient
- Phentermine
- OTC meds
- Pseudoephedrine
- Diphenhydramine
1st Gen Antipsychotic: Haldol
- Route:
- MOA:
- AEs:
- Benefits:
2nd Gen Antipsychotic: Olanzapine, Ziprasidone, Aripiprazole, Risperidone (PO), Quetiapine (PO)
- MOA:
- Efficacy:
- Safety profile:
- Haldol
- Route: PO, IM, IV
- MOA: Selective D2 receptor antagonist
- AEs: Prolonged QT with IV admin, high doses; EPS side effects
- Benefits: Low risk of resp depression with other CNS depressants
- 2nd Gen Antipsychotics
- MOA: D2 and Serotonin 2A receptor Antagonists
- Efficacy: Similar to Haldol, not inferior
- Safety profile: Not as well studied as haldol
- lower risk of prolonged QT, EPS
- Resp depression can occur with other CNS depressants
Benzodiazepines: Loraze, diaze, midazo
- Route:
- MOA:
- AEs:
- DDIs:
- Notes
Ketamine:
- Indication:
- Advantages:
- Disadvantages:
- Dose:
- BZDs
- Route: IV, IM, PO
- MOA: GABA receptor agonist, induces sedation
- AEs: Resp depression, hotn
- DDIs: EtOH intox, CNS depressants
- Notes:
- Not used as monotherapy for psychosis
- Avoid in elderly
- Ketamine
- Indication: excited delirium syndrome
- Advantages: rapid onset, no respiratory depression
- Disadvantages: may require rescue sedation, emergence phenomenon
- Dose: 5mg/kg IM
Dexmedetomidine:
- MOA
- Indication
- Advantages
- Disadvantages
- MOA: Selective alpha-2 agonist
- Indication: Sedation, delirium, severe EtOH withdrawal
- Advantages: Low risk of resp depression, less delirium induction
- Disadvantages: Hotn, bradycardia, hypertension
Your patient abuses drugs by the following routes, what are your route-specific medical considerations/complications?
- IV
- Nasal
- Rectal
- IV
- Infxn: bacteremia, endocarditis, cellulitis, abscess (cutaneous, spinal cord, brain, psoas muscle), osteo
- Retained foreign body
- DVT, arterial thrombosis, limb ischemia
- Poor venous access
- Nasal
- Loss of smell
- Nosebleeds
- Perf of nasal septum/soft palate
- Dysphagia
- Lung dz
- Rectal
- OD - bypasses liver/first pass
- Necrosis
- Inestinal ischemia, perforation
- Fecal incontinence
Describe your medical concerns for each of the following class of drug intoxication/abuse:
- Opioids
- Sympathomimetics
- EtOH
- Hallucinogens
- Opioids
- Life threatening resp/CNS depression
- Sympathomimetics
- Hyperthermia, tachycardia, htn, diaphoresis
- CHF, MI, arrhythmia, vasospasm, stroke
- Dehydration, rhabdo, renal failure
- Violence, psychosis
- Loss of pain perception
- EtOH
- Life threatening resp/CNS depression
- Delirium, agitation
- Starvation ketoacidosis
- Wenicke vs hepatic encephalopathy
- Delirium tremens/severe withdrawal
- Occult injury
- Hallucinogens
- Psychosis and agitation
- Potentially permament psychosis
Describe your dx workup for a patient who presents severely intoxicated
- None necessary if NO medical issues and patient admits to drug use
- Tox screening usually unnecessary
- If clinically indicated, workup is directed by age, comorbidites, likely complications
- Possible scenarios:
- Cardiac: EKG, troponin, BNP, monitoring
- Renal: BMP, CK, UA
- Intentional OD: ASA/APAP
- Infxn: Wound cultures, blood cultures
- Female: urine preg
- IVDA: CXR, PE screen
- Trauma: imaging