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Emergency Medicine > Psychiatry > Flashcards

Psychiatry Flashcards

Psych, also some psych related medication Emergencies! Study in conjunction with Toxicology.

You may prefer our related Brainscape-certified flashcards:
Royal College: Emergency Medicine flashcards
1
Q

What are risk factors for Suicide?

A 
Sex - male
Age (16-24, >65)
Depression - 20 fold incr MDD
Previous attempts
ETOH abuse (makes more impulsive)
Rational thinking loss (psychosis, anxiety)
Social supports lacking
Organized plan
No spouse
Sickness
Additional 
Trigger - acute stressors
Psychosis 
Access to means/lethal means
Previous psychiatry care
Excessive Drugs/ETOH abuse
Intent to kill - despite means used.

Contract to safety has not been shown to be beneficial and does not stand medico-legally.
But can ask if they feel safe with themselves..

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2
Q

What are factors that are protective in suicide?

A

SAFE

Social support
Awareness - insight and coping skills
Future orientation
Engaged - willing to engage in therapeutic process, does not withhold information

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3
Q

What are some positive symptoms of psychosis?

A

Hallucinations
Delusions
Disorganized Thought (disorganized thinking, thought blocking)
Disorganized Speech
Disorganized behavior ( Difficulties performing activities of daily living,Marked dishevelment or unusual or inappropriate dress, Inappropriate sexual behaviour, Unpredictable and untriggered agitation.Inappropriate affect (e.g., laughing while describing a personal tragedy).Catatonic behaviour.

Treated well by all anti-psychotics.

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4
Q

What are some negative symptoms of psychosis?

A

Flat affect
Avolition
Social withdrawal
impoverished thought and speech

Treated more effectively with atypical or 2nd gen anti-psychotics.

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5
Q

What are characteristics that are more suggestive of medical cause of psychosis?

A

MADFOCS
Memory deficits - recent
Activity - Psychomotor retardation, Tremor, ataxia

Distortions - visual hallucinations*

Feelings - Emotional lability
Orientation - Disoriented *
Cognition - Islands of lucidity, perceives occasionally, attends occasionally

Some others

  • Age >40
  • Sudden onset
  • Physical exam AbN
  • Vital signs AbN
  • Aphasia
  • consciousness impaired
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6
Q

What are characteristics more suggestive of psychiatric cause of psychosis?

A

MADFOCS
Memory - remote impairement
Activity - repetitive, posturing, rocking

Distortions - Auditory hallucinations*

Feelings - Flat affect
Orientation - Oriented
Cognition - continuous scattered thoughts, unfiltered perceptions, unable to attend or focus.

Some others:

  • Age <40
  • Gradual onset
  • PE Normal
  • Vital signs N
  • Social modesty
  • Intelligible speech
  • Awake and alert
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7
Q

List 4-5 complications/side effects of Neuroleptic/Anti-psychotic drugs

A
  1. Dystonia
  2. Akathesia
  3. Pseudoparkinsonism
    (first 3 are EPS)
  4. Tardive Dyskinesia
  5. Orthostatic Hypotension
  6. NMS
  7. Cardiovascular toxicity/dysrhythmias (QT prolongation)
  8. Agranulocytosis (clozapine - watch for neutropenia)
  9. Seizures (clozapine + others, lowers sz threshold)
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8
Q

What are symptoms of Dystonia?

What is the Rx?

A
  • involuntary m. contraction
  • Buccolongual crisis (sticking out tongue)
  • Acute torticollis
  • Oculogyric crisis - upward deviation of eyes
  • Opisthothinis - arching of back
  • Laryngospasm (rare)

Rx: Cogentin (Benztropine) 1-2mg IV/IM, Benadryl 25-50mg
Continue 48-72 hours

Of note: caused by dopaminergic-cholinergic balance in nigrostriatal pathways of basal ganglia.

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9
Q

What are the symptoms of Akathisia? what is the Rx?

A
  • Motor restlessness

Treatment: Betablockers (propranolol 30-60mg/day), Benztropine 1 mg BID-QID

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10
Q

What are the symptoms of pseudoparkinsonism?

A
  • Tremor, Rigidity, Akinesia, Postural instability.
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11
Q

What are the symptoms of Tardive Dyskinesia?

A
  • Involuntary movement of face and tongue in choreoathetoid nature
  • more common in elderly women
  • Rx: lower dose of anti-psychotic, +/- Benzos.
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12
Q

What are the symptoms of NMS? (Neuroleptic malignant syndrome)

A
  • Fever
  • Altered consciousness
  • Autonomic instability (BP, HR, sweating)
  • Rigidity (severe muscle) - ‘lead pipe’
  • Mental status changes (confusion)
    FARM
    Also:
  • Elevated serum CK
  • Respiratory failure, GI hemorrhage
  • Bradyreflexia

Thought to be related to dopamine depletion in CNS leading to defective thermoregulation in hypothalamus.

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13
Q

What is the treatment of NMS?

A
  1. stop neuroleptic meds
  2. Temperature regulation - cool
  3. Rehydration with IV fluids
  4. Supportive
  5. Benzodiazipines** (helps with m. relaxation too)
  6. Dantrolene (m. relaxant). 1mg/kg IV push, repeat until improve (max 10mg/kg)- not shown to be that effective in NMS (inhibits release of Ca from sarcoplasmic reticulum)
  7. Some benefit with Bromocriptine, Levodopa, Amantadine (small trial showed benefit) )Amantadine is a weak antagonist of the NMDA type glutamate receptor, increases dopamine release, and blocks dopamine reuptake.)
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14
Q

Serotonin syndrome vs. NMS

comment on onset, Neuromuscular findings, Causative agents, Treatment and resolution

A

Serotonin Syndrome

  • Onset: within 24 h
  • Neuromuscular findings: Hyperreactivity (tremor, clonus, reflexes)
  • Causative agents: Serotonin agents
  • Treatment: Benzos
  • Resolution: within 24 hours

NMS

  • Onset: Days to weeks
  • Neuromuscular findings: Bradyreflexia, severe muscular rigidity
  • Causative agents: Dopamine antagonist
  • Treatment: Benzo’s Bromocriptine (dopamine agonist), Dantrolene
  • Resolution: Days to weeks
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15
Q

For Major Depressive disorder you need >5 of which symptoms, almost everyday for 2 week period and have either depressed mood or anhedonia (loss of interest/pleasure)

A
  1. Sleep - hypersomnia, hypsomnia
  2. Interest loss
  3. Guilt (excessive), or feelings of worthlessness
  4. Mood - depressed (irritable in peds)
  5. Energy loss, fatigue
  6. Concentration poor, or indecisiveness
  7. Psychomotor agitation/retardation
  8. Suicidal ideation or recurrent thoughts of death or suicidal plan or attempt.
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16
Q

What are symptoms of Mania?

A 
DIGFAST
Distractibility
Irritable
Grandiosity
Flight of ideas
Activity increased
Sleeplessness
Thoughtlessness (impulsive, incr risk taking)

Also: pressured speech, inflated self esteem, incr in goal directed activity, incr. involvement in pleasurable activities with painful consequences.

17
Q

When is the typical onset of post partum depression?

A

Onset within 4 weeks of delivery

18
Q

What are the 2 types of Bipolar d/o?

A

Type I - Mania and MDD
Type II - Hypomania and MDD
hypomania include features of manic without psychosis

19
Q

What are some conditions associated with depression?

A 
o	Parkinson’s
o	Malignant neoplasms
o	CAD -After MI pts with depression experience 3.5 fold increase in CV mortality
o	MI
o	Stroke
o	End stage renal disease
o	HIV/AIDs
o	Endocrine
o	CT disorders
o	Diabetes - Those with this are more likely to have depression
20
Q

What are symptoms of Serotonin Syndrome?

A 
'HARMED'
Hyperthermia
Autonomic instability
Rigidity (not as much as NMS)
Myoclonus
Encephalopathy
Diaphoresis
21
Q

What are examples of typical (1st generation) and atypical (2nd generation) anti-psychotics?

A

Typical: More EPS

  • Haldol
  • Droperidol
  • These are high potency, there are low.

Atypical (less s/e), better for negative symptoms

  • Clozapine
  • Quetiapine (Seroquel)
  • Risperidone
  • Ariprazole
  • Olanzapine
22
Q

Describe the monoamine hypothesis for depression

A

Depressive symptoms are mediated through an imbalance of dopaminergic, noradrenergic and serotonergic systems.
- Anti-depressants typically act to increase synaptic monoamine concentrations.

23
Q

In patients that take non-selective MAOIs (monoamine oxidase inhibitors) ingestion of what sympthomimetic amine is responsible for hypertensive crisis?

A

Tyramine

24
Q

What foods are high in tyramine?

A
  • Aged cheese
  • Red wine
  • smoked or pickled or aged meat
25
Q

Why does ingestion of tyramine rich food cause hypertensive emergencies in the presence of MAOIs?

A

Tyramine is an indirectly acting sympthomimetic amine, it is normally cleared by monoamine oxidase, when this is inhibited tyramine is absorbed systemically and enters presynaptic vesicles causing release of norepinephrine and serotonin into the synapse leading to hypertensive crisis (headache, hypertension, flushin, diaphoresis)

  • This syndrome can occur 3 weeks after discontinuing MAOIs.
  • Can also precipitate serotonin syndrome..
26
Q

What are some examples of drugs that interact adversely with MAOIs?

A
  • Agents that have Serotonergic effects (Serotonin, Norepinephrine, and/or Dopamine Reuptake Inhibitors, TCA)
27
Q

Outline Management of MAOI toxicity

A
  • CNS excitation: Benzos
  • Hypertension (only if severe): Nitroprusside or Phentolamine (No BB for same reason as sympathemimotics - unopposed alpha)
  • Hypotension: Crystalloids, if refractory NE,E NOT dopamine
    (this is b/c hypotension and CV collapse after MAOI usu due to catecholamine depletion so indirect acting agents ie. dopamine wont work)
  • Hyperthermia: cooling, IV rehydration
28
Q

How do TCA’s work in respect to depression?

A

Monoamine reuptake inhibition

29
Q

For TCA OD, in what time frame should you appreciate symptoms if there was a significant ingestion?

A

6 hours

30
Q

What are the early signs in TCA toxicity? Later signs?

A

Early

  • anticholinergic effects
  • speech is often rapid and mumbling
  • Seizures may occur
  • Hypertension

Late

  • Myocardial depression (hypotension and bradycardia) - this is from severe Na channel blockade
  • Depressed LOC
  • Seizures
  • Cardiac dysrythmias
31
Q

What are the pathophysiological effects of TCAs?

A
  • Na Channel blockade (see widened QRS)
  • Block K+ efflux (get QT prolongation)
  • combined effects on various ion channels (aLOC, seizures, hypotension, wide complex tachycardia)
32
Q

What are the components of the MSE?

A 
Appearance
Attitude
Behavior
Mood and affect
Speech
Thought process
Thought content
Perceptions
Cognition
Insight
Judgment

Emergency Medicine (39 decks)

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