Psychiatry/ Child abuse Flashcards
Definition of colic? (wessel criteria)
crying for no apparent reason that lasts for ≥3 hours per day and occurs on ≥3 days per week for > 1 week in an otherwise healthy infant < 3 months of age
DDx of inconsolable crying
FB or corneal abrasion** *maybe up to 21%! Fluorescein for diagnosis) otitis media meningitis CMPA constipation, GERD CHD hernia or torsion hair tourniquet NAI drug withdrawal irritability after pertussis vaccine (up to 24 hours)
Colic counseling (list 4)
o Soothing baby: rocking, riding in a car, white noise, swing
o Family support
o Normalize but acknowledge how difficult it is
o Most improve by 3 months
o Risk for NAI: place baby down in safe space if feeling overwhelmed
6 non-psychiatric causes of a violent/aggressive patient?
- CNS (tumour, abscess, head injury)
- Hypoxia
- Hypoglycemia/calcemia
- Hyperthyroidism/wilsons’
- Vasculitis (i.e. SLE)
- Infections (i.e. meningitis, HIV)
- Toxins (i.e. cocaine, amphetamines, PCP, corticosteroids)
4 psychiatric causes of a violent/aggressive patient?
- Disruptive behavioural disorders (ex. ODD, ADHD, CD)
- Depression
- Mania/mixed manic-depressive states
- PDD (ex. ASD)
- Psychosis
4 predictors of violence and aggression in agitated patient
- Recent acts of violence
- Verbal or physical threats
- Carrying weapons
- Intoxication (alcohol vs others)
- Concrete plan
Delirium DDx?
I Watch Death:
Infectious
Withdrawal Acute metabolic Trauma CNS pathology Hypoxia
Deficiencies (B12, folate) Endo Acute vascular (ie. stroke) Toxins Heavy metals
Major side effects of typical antipsychotics
Anti-dopaminergic:
EPS (acute dystonic reactions, akathisia, parkinsonian effect)
Treatment of acute dystonic reaction
Tx with PO/IV/IM diphenhydramine or PO/IM benztropine, benzo’s
Worrisome side effect of buproprion
Seizures
Diagnostic criteria of depression
MSIGECAPS: at least 5 for at least 2 weeks
at least one of the symptoms is either dysphoria or anhedonia
What is the most dangerous side effect of SSRIs in adolescents?
Serotonin syndrome
QTC prolongation – citalopram > 40 mg
Clinical features of serotonin syndrome?
o Use of an SSRI o Agitation o Stupor o Myoclonus o Hyperreflexia o Diaphoresis o Shivering o Tremor o Diarrhea o Incoordination o Fever
Tx of serotonin syndrome
Supportive
Discontinue offending agent
benzo’s
cyproheptadine
Clinical features of neuroleptic malignant syndrome
o Fever o Axial muscle rigidity o Autonomic instability/shock o Altered LOC o Elevated CPK o Leukocytosis
Tx of NMS
o Supportive o IV fluids o Antipyretics o D/C medication o Bromocriptine and Dantrolene specific antidotes
3 autonomic and 3 neuromuscular findings of serotonin syndrome?
- Autonomic findings: diaphoresis, tachycardia, hyperthermia, hypertension, vomiting, and diarrhea
- Neuromuscular findings: tremor, muscle rigidity, myoclonus, hyperreflexia, and bilateral Babinski sign
Criteria for diagnosis Bipolar disorder
DIG FAST
Elation or elevated mood or irritability (irritability more common in Peds):
- Distractibility
- Impulsivity
- Grandiosity
- Flight of ideas
- Activity increase
- Sleep (decreased)
- Talkative
(need at least 3 for 1 week duration, or shorter if hospitalization required)
Definition of conversion disorder
one or more symptoms of altered voluntary motor or sensory function that are incompatible with recognized neurologic or medication conditions that cause significant distress and/or impairment of functioning
Tips for dealing with child with autism in the ED
- Communicate directly with child
- Simple and concrete language
- Brief instructions
- Warn about transition
- Offer positive reinforcement
- Allow frequent breaks
- Recognize when tasks are overwhelming
What is the school refusal triad?
- Vague physical symptoms
- Normal physical and laboratory findings
- Poor school attendance
3 comorbidities associated with school phobia
- Anxiety
- Depression
- Specific phobias
- Conduct disorder
- Substance abuse
- Familial psychopathology
Basic mental status exam? (ABC’s)
ABC’s of mental status exam:
appearance/affect
behavior
cognition (thought content, thought process, LOC)
4 ways to talk down an agitated patient (ie. no meds)
Introduce yourself Simple language Explain what is happening/next steps Reduce environmental stimulation (dark room, less people) Offer food or drink Room for pacing, if possible Listen and empathize
Examples of chemical restraints
- Mild agitation: antihistamines, alpha-adrenergic agents such as clonidine or benzodiazepines
- Moderate to severe: benzodiazepines, alpha-adrenergic, typical antipyschotics, atypical antipsychotics. Can give combo of benzo and antipsychotic together for rapid tranquilization.
- Commonly used medications include benzodiazepines (eg. lorazepam IV/IM/SL), and typical antipsychotics (Haloperidol) and atypical antipsychotics (olanzapine or risperdal IM/PO)
- Classic adult combo = 2 mg lorazepam + 5 mg Haldol
List five things to do when applying restraints.
o Explain to the patient why physical restraints are necessary o Have at least 5 caretakers (trained) to apply – 1 for the head and 1/limb o Avoid pressure on the patient throat or chest o Avoid placement of a restrained child in prone position o Close (1:1) supervision while the child is in restraints o Assess restraints q2 hrs (teenager) o Face to face with physician at 1 hour mark o Remove restraints with adequate staff present and when patient has regained control (may choose to remove one limb at a time – but don’t leave only 1 limb in place)
Complications of physical restraints?
o PTSD o Shame/violation o Injury o Asphyxiation, airway obstruction o Also: pressure sores (skin breakdown), paresthesias, rhabdomyolysis
Name 4 reasons to put someone in physical restraints:
o To prevent imminent harm to the patient or other persons when the means of control (verbal) are not effective or appropriate
o To prevent serious disruption of the treatment plan or significant damage to the physical environment
o To decrease the stimulation a patient receives (PCP, ethanol intoxication)
o When the patient feels out of control and is requesting it
o Unable to give chemical restraint (safety or refusal and continued aggression
Risk factors for suicide?
SAD PERSONS mnemonic
Sex: male
Age < 19, > 65
Depression
Prev attempt Excessive alcohol/drugs Rational thinking loss Separated/divorces Organized attempt No social supports Stated future intent
What are the 3 most commons causes of mortality in teenagers ages 15-19y in North America.
- Accident death – MVC
- Homicide
- Suicide
Teenage female brought in to ED with desire to die. List six common risk factors of suicide completion in teenagers.
- Adolescents >16
- Previous suicide attempts
- History of comorbid psychiatric condition (Depression, Anxiety)
- Recent stressor, change in life
- Substance abuse, alcohol or drug abuse
- Poor social support
- Family history of mental illness
- Homosexual orientation
- History or recent sexual/physical abuse
- Males>Females
- Access to lethal weapons or medications
Indications for psych admission after suicide attempt
- no rapport with physician
- serious attempt (lethality, intent)
- still actively suicidal
- can’t engage in safety planning
- psychosis
- no family support
- child denying significance of attempt
Time cutoff after which physical exam in the ED for suspected abuse is NOT indicated
72 hours
Examples of date rape drugs (3)
Rohypnol (flunitrazepam) and GHB (Y-hydroxybutyrate), ketamine
List 5 conditions associated with genital redness
vulvovaginitis contact dermatitis perianal strep candida diaper rash lichen sclerosis
Teen sexually assaulted 12 hours ago, vaginal pain and bleeding. List 5 things to do in management
- genital exam
- Contact scan
- sexual assault evidence kit
- EC, pregnancy test
- STI testing and prophylaxis
- Hep B and HIV prophylaxis
When to screen for STI’s in a prepubertal victim of sexual assault?
screened for STI if symptoms are present, history or evidence ejaculation or oral/genital penetration, assailant has STI, high community prevalence STI, patient or parents requests STI testing
When to screen for STI’s in a post-pubertal victim of sexual assault?
screen ALL
Which 4 STI’s are diagnostic of sexual assault (if excluded vertical transmission)
gonorrhea, chlamydia, syphilis, HIV
Adams paper - list findings diagnostic of injury
Acute laceration to external genital/anal tissue
Hymenal laceration
bruising of the hymen
hymenal transection
missing segment of hymenal tissue (particularly at posterior pole)
Sexual assault post-exposure prophylaxis for STI’s?
GC+ chlamydia: Azithromycin 1g, ceftriaxone 250 mg
Trich: flagyl 2g PO x 1
HIV: consider HIV PEP
Hep B immunization
Timing for emergency contraception after sexual assault, and what to use
offer in pubertal females within 120 hours (ex progestin only ECP 1.5 mg levonogestrel); repeat testing in 2 weeks
What are 4 psychosocial risk factors for pediatric sexual abuse
- Non-two parent household
- foster care
- single parent with live in partner
- female
- age 7-13
- African American/Hispanic
- disabled
- behaviour difficulties
- Previous abuse/neglect
What are 4 clinical presentation of child sexual assault
Anxiety, nightmares, PTSD, inappropriate sexual behavior, aggression, school problems, hyperactivity, and regressive behavior.
Sexual assault - name 3 viruses of concern that you would discuss with the parents
HIV
HPV
Hep B/C
5 Risk factors for STI in sexual assault:
a. High prevalence of STI in the community
b. Presence of STI in family member
c. Suspected perpetrator has known STI
d. Suspected perpetrator is at high risk for STI
e. Evidence of penetration or ejaculation
f. Multiple assailants
A 13 year old presents with concern about STI acquisition
15 years old (non-exploitative, not in a position of power).
12-13: 2 years older
14-15: 5 years older
age of consent = 16 years old (18 for exploitative)
What are 3 reportable STI
HIV/AIDS
Chlamydia
Syphilis
Gonorrhea
AN - DSM5 criteria for diagnosis
- Restriction of energy intake
- Intense fear of gaining weight
- Distorted perception of body weight and shape
(not amenorrhea)
List five cardiac problems in anorexia nervosa.
- Orthostatic vital sign changes
- Hypotension
- Bradycardia
- Myocardial atrophy
- Mitral valve prolapse
- Pericardial effusion
- Arrythmias
o QT prolongation
o Torsades ventricular fibrillation
o AV block
o Prolonged PR – interval
o ST-T wave abnormalities
Anorexia - What are 4 investigations to order in the ER in initial work up
CBC/diff, electrolytes/extended electrolytes, ECG, renal function
TSH
Orthostatic vitals
Anorexia - 5 indications for admission
HR < 45 BP < 80/50 electrolyte abnormalities arrythmias/ QT prolongation orthostatic changes suicidality acute food refusal failed outpt treatment
Features of refeeding syndrome
Hypophosphatemia (hallmark) Hypokalemia Vitamin (e.g. thiamine) deficiencies CHF Peripheral edema
Bulimia - 4 physical signs
- enlarged parotids
- poor dentition/erosion of enamel
- callused knuckles/fingers (Russell’s Sign)
- xerosis (dry skin)
- edema
- hair loss
Bulimia - 2 serious complications
- arrhythmias
- electrolyte disturbances
- esophageal rupture
- dehydration
- metabolic acidosis
- menstrual irregularities
What is the definition of child neglect?
Neglect refers to omissions (physical, emotional, educational), resulting in actual or potential harm. Neglect occurs when a need is not adequately met and results in actual or potential harm, whatever the reasons.
What are four physical findings seen with neglect?
● Weight loss or failure to thrive ● Poor hygiene ● Diaper rash ● Flat and balding occiput ● Dull apathetic facies ● Body posture of an under-stimulated child ● Excessive oral self-stimulation ● Developmental delay, particularly in social adaptive and language areas
List five features that would make a history suspicious for non-accidental trauma?
- Changing story
- Delayed presentation for injury
- Unexplained injuries
- Injury pattern not consistent with developmental age
- Vague history
- Nature of interaction between parent – child and parent – ED staff
- Child brought in by a different caregiver who was not present at time of injury
List 5 factors that increase the risk of child abuse
- Child factors: developmental handicaps, chronic illness, behavioral issues, prematurity, other associated injuries, multiples (twins)
- Parent factors: young age, lower SES, substance use, mental health disorders, personal hx of childhood abuse, hx of criminality, violence
- Environment factors: low education, lack of supports, unemployment, intimate partner violence, non-related adult male in home
Concerning bruising for child abuse
TEN4
Bruising of the Torso, Ear, or Neck in a child ≤4 years old, or bruising in any location in a child <4 months old worrisome
Concerning fractures for child abuse
CML (classic metaphyseal lesions) Posterior rib scapula vertebral spinous process sternum
DDX of causes fractures (for NAI):
trauma (including accidental and birth injuries), nutritional (rickets, osteopenia, copper deficiency), genetic (OI, menkes), infectious/inflammatory (osteomyelitis), neoplastic (leukemia, bone tumor)
How to screen for other injuries in NAI?
- Skeletal survey if < 2 years old
- CT head or MRI if < 1 year old or symptomatic
- Ophtho exam if + head imaging
- Abdo labs (AST, ALT (cutoff > 80), amylase) +/- CT abdomen
- Labs for bruising work-up (CPS): CBC, diff, smear, INR, PTT, vWF studies, blood group, fibrinogen, factor 8, 9, LFT’s, urea/creatinine
Examples of abnormal sexualized behavior
behaviours btw children 4 or more years apart, one child takes charge and directs time/place/type, asking adults to engage in specific sexual acts, obsessive masturbation difficult to distract
List the five most common historical features of Munchausen Syndrome by Proxy.
- Single parent – usually mother. Distant relationship with father
- Articulate and cooperative
- History of ‘Doctor Shopping’
- Multiple work ups without any medical diagnoses
- Episodes of illness witness by parent only – always present when episode happens, not witnessed during admissions or by medical professionals
- Secondary gain from medicalization or admission
- Symptoms and course, response to treatment are incompatible with identifiable diagnosis
- Parental history of factitious or somatoform disorders or extensive medical care
Breath-holding spell. 2 tests to do in ED?
ECG, CBC (R/O anemia)
