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
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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
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3
Q

Risk Factors for DT and seizures

A
  • Severe dependence
  • Past delerium tremens
  • Older patients
  • Physical illness
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4
Q

Delerium Tremens Prognosis

A
  • 10% mortality if untreated
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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
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6
Q

Effect of Lithium on the Heart

A
  • Bradycardia
  • Syncope
  • Hypotension
  • Sinus node dysfunction
  • Flattening of T-waves
  • Oedema
  • Arrythmias
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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16
Q

Anorexia Nervosa - Inpatient Treatment Medical Interventions

A
  • Weight restoration and monitoring - aim for weight gain betweek 0.5-1kg a week over 8-12 weeks
    • Dietician guided - target weight, 2500-3000 calories today over 3-4 meals plus snacks
  • Rehydration and correction of serum electrolytes
  • Following wieght restoration patient should be offered outpatient psychological treatment and physical monitroing should continue for at least 12 months
  • No medication for anorexia specifically - Fluoxetine, TCAs may be used for comorbid depression
17
Q

Anorexia Nervosa - Psychological Interventions

A