SPMM Notes Flashcards
1
Q
Delerium Tremens - Definition and Onset
A
- Toxic confusional state due to severe alcohol withdrawal symptoms
- Symptoms peak 72-96 hours after last drink
2
Q
Delerium Tremens Symptoms
A
- Cognitive
- Confusion
- Clouding of consciousness
- Agitation
- Sleep disturbance
- Psychiatric
- Vivid hallucinations in all modalities
- Fleeting paranoid delusions
- Physical
- Severe tremor
- Fever
- Sweating
- Tachycardia
- Hypertension
3
Q
Risk Factors for DT and seizures
A
- Severe dependence
- Past delerium tremens
- Older patients
- Physical illness
4
Q
Delerium Tremens Prognosis
A
- 10% mortality if untreated
5
Q
Delerium Tremens - Management
A
- Treat any underlying infection, dehydration
- Ensure adequate fluid and electrolyte balance, give nutrition
- Optimise environment - well lit quiet room with adequate lighting
- Nursing support - offer consistent nursing with reassurance, reorienttation and explanation
- Chlordiaxepoxide sliding scale reducing regimen
- IM benzodiazepines may be used judiciously for quick sedation and safety
- IV Pabrinex (Thiamine supplementation
- Avoid Haloperidol (phenothiazine antipsychotics) due to risk of inducing seizures
- Warn about risk of withdrawal seizures and Wernicke’s encephalopathy
6
Q
Effect of Lithium on the Heart
A
- Bradycardia
- Syncope
- Hypotension
- Sinus node dysfunction
- Flattening of T-waves
- Oedema
- Arrythmias
7
Q
Lithium and Amiodarone
A
- Cardiac rrisk - may increase risk of prolonged QT and Torsade de Pointes i.e. serious arrythmias
- Increased risk of sudden hypothyroidism
8
Q
Lithium Induced Hypothyroidism
A
- About 20% of middle-aged women taking lithium long term present with hypothyroidism
- Usually reversible
- Easily treated with thyroxine - advised if raised TSH and any affective symptoms
- Not a contraindication for continuing lithium per se
9
Q
Antidepressants in Cardiac Disease
A
- Sertraline best according to SADHEART
- Mirtazapine also safe
- TCAs arrythmogenic due to Na/K channel blockade, also cause hypotension/hypertension
- Fluoxetine - hepatic enzyme inductor therefore could affect levels of cardiac drugs e.g. amiodarone
- Venlafaxine - may cause hypertension
- Citalopram/Fluvoxamine - some QTc effects, require ECG monitoring
10
Q
Treatment Resistant Depression - Algorithm
A
- By definition 2 different antidepressants tried for >6 weeks at adequate dose
- Augmentation options:
- Lithium
- Thyroxine
- High dose venlafaxine
- 5HTP
- SSRI + Mirtazapine
- Psychological interventions?
- CBT
- Family therapy
- Psychotherapy
- If still no response second opinion
- ECT if all other measures fail (with consent)
11
Q
Venlafaxine - Indications, Contraindications and Monitoring
A
- NICE - reserve for failing to respond to two trials of other antidepressants
- Before initiating - ECG, electrolytes and BP should be measured
- Contraindicated in patients with:
- Heart disease (including ECG abnormalities like prolonged QTc)
- Electrolyte imbalances
- Hypertension
- Also inquire about:
- FHx heart disease
- Other medication that might interact
- Take into account higher burden of side effects therefore patients more likely to discontinue, also higher propensity for withdrawal syndrome
- Monitor BP +/- U+Es every 6 months
- If signs of heart disease taper off slowly over a period of weeks/months
12
Q
Pregnant Woman Using Heroin - Management
A
- Outpatient detoxification - best time is during second trimester
- Lowest possible dose of methadone
- Random UDS and daily methadone pickup
- Treat comorbid psychiatric conditions like anxiety and depression
- Work with obstreticians throughout and paediatricians around delivery - risk of neonatal opioid withdrawal syndrome
- Opioid misuse not itself reason to involve SS but should do if concerns about welfare of child - may need child protection proceedure
- Can also help with housing
- Methadone compatible with breastfeeding and can be continued at a low dose after delivery
- Consider couples/family therapy - useful if partner uses substances
13
Q
Neonatal Complications of Opioid Misuse in Pregnancy
A
- Increased risk of miscarriage or intrauterine death
- Baby more likely to be premature or low birth weight
- Neonatal opioid withdrawal symptoms
- Respiratory depression
14
Q
Anorexia Nervosa - Inpatient Treatment Criteria
A
- BMI <13.5
- Severe depression and suicidal risk
- Rapid weigh loss in patients with a dangerously low weight
- Electrolyte imbalances leading to ECG changes (low K<3 mmol/L)
- Crisis situation
- Failed outpatient care (non-compliance)
- Dehydration
- Refusal to eat and drink
15
Q
Anorexia Nervosa - Inpatient Treatment Goals
A
- Setting should be appropriate for skilled refeeding, physical monitoring plus psychosocial interventions
- Goals are:
- Addressing physical and psychiatric complications
- Development of a healthy meal plan and weight gain/restoration
- Addressing underlying psychological conflicts such as low self-esteem and planning new coping strategies
- Enhancing communication skills