SUD Emergencies Flashcards
What is the first line agent used in the agitated patient ?
second generation antipsychotics
What is the BBW for haloperidol?
risk of use for dementia related psychosis.
lengthens QT interval
motor related side effects
DONT USE AS SINGLE AGENT
Ketamine is proposed as treatment for both, patients with ________________, which is when a patient is at high risk of death if not emergently treated and for patients who have proven _________________.
excited delirium
refractory to other antipsychotics
What two medications do you want to avoid in the elderly population?
benzo’s and antihistamines- prolonged sedation/agitation.
What is the most prevalent substance use problem in adults?
alcohol abuse.
What is the preferred pharm for elderly?
risperidone, olanzapine, quetiapine, haloperidol
Patients with dementia are more likely to develop delirium and patients who experience delirium are more likely to develop dementia later on in life.
What is delirium? What are the 3 main types?
- acute change in cognition that fluctautes RAPIDLY over time and is REVERSIBLE
- Delirium is frequently the first sign of an underlying acute medical illness
- Patients demonstrate altered level of consciousness, inattention, disorganized thinking, altered perception.
3 types:
1. hyperactive
2. hypoactive
3. mixed
Delirium is a common disorder in the ______________.
elderly
What are the environmental risk factors for delirium ?
- functional dependence
- living in a nursing home
- hearing impairment
The ED is an independent predictor of ___________ mortality when it comes to delirium.
6 month
You ALWAYS want to check this lab- ______________ in patients with delirium. Infection often manifests as _______________ in elderly, most common being ______________, also COVID-19
glucose
AMS
UTI
In a patient with delirium, you want to avoid precipitating factors iatrogenic delerium in the hospital:
1.
2.
3.
4.
- physical restraints
- malnutrition
- use of a bladder catheter
- more than 3 meds added at a time
Dementia is defined as significant decline in cognitive function in one or more of the following cognitive domains:
- learning and memory
- language
- executive function
- complex attention
- perceptual motor
- social cognition
_________________ is the most common type of dementia.
alzheimer’s
What is sundowning
it is when patients with dementia experience behavioral disturbances
Patients with lewy body dementia do poorly when given ______________ so AVOID THEM in these patients.
typical antipsychotics.
The DSM 5 requires ____________ of the 11 criteria for diagnosis of substance and alcohol use disorder and determines severity. Also terminology is “alcohol use disorders” mild, moderate or severe.
2 or more
Binge drinking is blood etoh level over the US legal limit of _______________
average male =
average female=
0.08 g/dL
4 drinks in 2 hours
3 drinks in 2 hours
Acute alcohol intoxication is BAL of ______________
> 0.080 g/DL
Alcohol related disorders:
Syndrome and their clinical findings
1. Minor withdrawl
2. seizures
3. alcoholic hallucinations
4. delirium tremens
- mild anxiety, HA, diaphoresis, palpitations, anorexia, GI upset, normal mental status
- generalized tonic-clonic, short post ictal period
- visual, auditory, and or tactile hallucinations with intact orientation and normal VS
- delirium, agitation, tachy, HTN, fever, diaphoresis
If alcohol withdrawal does not progress, symptoms generally resolve within 24-48 hrs. If 24 hours pass since the last drink without development of symptoms in someone not at risk for major withdrawal… what is the treatment?
no medications are indicated since symptoms are unlikely to develop
Clinical institute withdrawal assessment for alcohol. (CIWA-Ar)
0-9 points=
10-15 points=
16-20=
21-67 =
very mild withdrawal
mild withdrawal
modest withdrawal
severe withdrawal
What is the ambulatory manangement for mild symptoms of alcohol withdrawal (CIWA-Ar) less than 15 or asymptomatic pts with a hx of symptoms with past attempts to reduce their drinking.
- longer acting benzo’s such as chlordiazepoxide or diazepam
- short acting for hepatic impairment - lorazepam
What is the criteria for an inpatient alcohol withdrawal detox?
fever disorientation drenching sweats
severe tachy
hypotension
pregnancy
concurrent substance use that lead to withdrawl sx e.g. benzos
abnormal labs
Withdrawal seizures can occur in patients that are going through alcohol withdrawal. They are __________________ convulsions in patients with a long history of chronic alcoholism as evidenced by their typical onset during 4/5th decades of life. These seizures are usually ______________ or occur briefly for a short period.
generalized tonic-clonic
singular
What is the treatment for alcohol withdrawal?
What dont you want to use ?
IV therapy with benzodiazepines: Diazepam 5-10 mg IV every 5-10 min. until appropriate level of sedation
IV fluids, banana bag
DONT use ethanol, antipsychotics (lowers sx threshold), anticonvulsants, clonidine
If a patient with alcohol withdrawal is minimally symptomatic or asymptomatic and are admitted to the hospital for other reasons, can be prophylactically treated with _________________.
oral benzo’s
What are the 5 drugs that you want to test for with patients with substance abuse/misuse?
- amphetamine ( 2-3 d)
- cocaine (2-3 d)
- cannabis (1-7 d)
- some opiods (1-3 d)
- phencyclidine (7-14)
What are the signs of acute intoxication of opioids?
- depressed mental status or euphoric
- decreased RR
- decreased TV
- decreased bowel sounds
- miotic (constricted) pupils
What is the treatment for opioid overdose?
If O2 sat is <90 but breathing spontaneously = give O2 followed by IV or IM naloxone 0.04 mg repeat until end goal.
If apneic, ventilate using BVM attached to supplemental oxygen and give naloxone in doses of 0.2 to 1mg IV of IM. if no response after a total of 5-10 mg, tracheal intubation
Opioid withdrawal is onset of 4-12 hours after the last dose of short acting, 24-48 hrs after cessation of a longer acting _____________. Peak within _______________ of onset and persists for several days (short acting agents) and up to _______________ with methadone.
methadone.
24-48
2 weeks
What are the symptoms of an opiod withdrawl?
What will you see on exam?
What is the treatment?
Symptoms:
craving it
dysphoria and restlessness
rihnorrhea and lacrimation
myalgias and arthralgias
N/V abdomiinal pain and diarrhea
Exam:
myadriasis (pupillary dialtion)
yawning
diaphoresis
rhinorrhea
increased bowel sounds
piloerection
Tx: promethazine, loperamide
AUD meds for management
disulfiram
and meds that reduce alcohol consumption such as acamprosate, oral naltrexone, long acting injectable naltrexone
SUD meds for management
methadone AND buprenophrile are referred to as opiod agonist treatments.
Polysubstance use is common among those that use cocaine.
What is their clinical presentation?
When combined with alcohol> _____________________
What is the treatment?
presentation:
hyperawareness
hypersexuality
hypervigillance
psychomotor agitation
formication (feeling of bugs crawling on skin)
cocaine induced psychosis
cocaine delirium
cardiotoxic metabolite cocaethylene
Tx: these patients present with mild depressive sx but self limited, no specific treatment
Methamphetamine intoxication can produce either ______________ or _______________ or elevated or decreased _______________ and either psychomotor agitation or retardation along with some psychiatric effects. How is this best handled?
tachy, brady
BP
By “talking down” and symptomatic management
Cannabis intoxication includes euphoria, anxiety, impaired judgement, social withdrawal, conjunctival injection, increased appetite, dry mouth, tachy, sensation of slowed time or impaired motor coordination. urine remains positive for ____________________ but can remain positive for 1 month for chronic users. Treatment is ___________________.
48 hrs- 7 days
symptomatic- hot water showers and capsaicin
Synthetic marijuana:
synthetic cannabinoid agonists are comprised of blends of various types of plant material sprayed with a synthetic cannabiinoid and other psychotropic designer agents, including salvia divinorum and kratom. What is the treatment?
supportive and symptoms based- benzos and antipscyhotics
Gamma-hydroxybutyric acid (GHB) causes a profound _______________ without alteration of________________ or ______________ and can rapidly wear off yielding an alert and awake patient. Is it detected on standard urine toxicology screens?
CNS depression
vital signs, respiratory drive
No
What is psychosis?
DSM 5: abnormalities in one or more of the five domains…
These patients may also present with _________________.
derrangement of the mind characterized by defective or lost contact with reality.
1. hallucinations
2. delusions
3. disorganized or abnormal motor behavior
4. disorganized thinking
5. negative symptoms
schizophrenia
In patients with psychosis, you want to rule out potential underlying causes especially if:
1.
2.
3.
- new onset psychosis
- greater than 35 y/o with no previous history
- visual hallucinations
Steroid induced pscyhosis can develop within 5 days - usu in doses _____________ of _______________
> 40 mg, prednisone
What is the treatment for psychosis?
typical antipsychotics: high potency meds (haloperidol) = less sedating but prolonged QT ‘
atypical antipsychotics: olanzapiine, ziprasidone. BUT can cause acute dystonia.
What is the most important part of the evaluation of depression?
What is the clearest risk factor?
assessment of suicide risk.
prior suicide attempt
What is considered non-suicidal self injury? ____________ may be present in the ER with chronic suicidality of NSSI.
________ is typically NOT initiated in the ED but resumption of a well tolerated, recently stopped med may be considered.
self harm behavior - cutting, burning or self mutilation
borderline personality disorder (BPD)
antidepressants
Which medication may initially increase suicidal ideation (esp in < 25)?
What occurs when this medication is abruptly stopped or rapidly decreased in dosage?
SSRIs
withdrawal syndrome- flu like symptoms, including nausea, vomiting, fatigue, myalgias, vertigo, HA, insomnia, parasthesias
Who is most at risk for suicide attempt?
- white men > 45
- adolescents
- veterans
- american indian teens
5.agricultural workers, physicians, attorneys, veterinarians - youths and adults part of LGTB+ community
7.persons with mental illness, disabilities, chronic pain
Bipolar is typically characterized by _________ typically cycling with periods of ______________. What is mania? How is it treated in the ED setting?
mania, depression.
Mania is inflated self esteem or grandiosity, decreased need for sleep, pressured speech, flight or ideas or racing thoughts, distractibility, increase in goal directed activity or psychomotor agitation, involvement in high risk activites (often sexual or financial in nature)
in the ED setting- may be treating the agitating or restarting meds that they stopped (common) - lithium, valproic acid, carbamazepine, antipsychotic.
What are anxiety disorders?
1.
2.
3.
GAD, panic, PTSD
Which population of patients have a 10 fold greater suicide risk compared to the general population?
those with anxiety disorders.
_________________ may be considered for an acute panic attack. it is ONLY short term use given potential for abuse and dependence. Ativan vs Xanax.
benzodiazepines
Which two eating disorders have onsets around 18? Which one occurs in older patients? Which one is more likely in men?
anorexia and bulimia
binge eating
binge eating more likely in men
What are the medical complications of eating disorders?
CP and hematemesis caused by mallory weiss tear from purging
palpitations from dyshrythmias
dysmenorrhea
fractures from osteoperosis
What are the cardiopulmonary complications that occur as a result of anorexia?
- decreased cardiac muscle mass
- increased vagal tone
- hypotension
- bradycardia
- orthostasis
- increased QT dispersion = increased arrhythmic risk
What are the GI complications associated with bulimia?
mallory weiss tears
renal/electrolyte derangement:
metabolic alkalosis
hyponatremia - from diuretic use
hypochloremia from vomiting
potassium/mag depletion from laxative and enema abuse
In patients with bulimia, there is an increased risk of ____________ during the first week of refeeding after severe nutrient depletion (loss of phosphate)
cardiac complications
The ____________ is useful for screening anorexia, bulimia in a brief encounter.
SCOFF questionnaire
sick, control, one stone, fat, food
What initial testing should be done in the evaluation of eating disorders?
ECG
CMP
CBC
pregnancy
urinalysis
hepatic functional panel
serum albumin
lipase
amylase
TSH
Factitious disorder imposed on self - 20-30 yr olds clinical presentation
- falsification of signs or symptoms or induction of injury or disease associated with deception
- presents to others as injured, ill, or impaired
- deceptive behavior
- behaviors not explained by another mental disorder
often wander from hospital to hospital (“doctor shopping”), demand hospital admission, refuse discharge, and exhibit extensive medical knowledge
For involuntary admission, there MUST BE……..
What does this exclude?
What does this include?
a prospect of recovery if the patient is treated involuntarily.
intellectual disabilities, autism, substance use disorder
- harm to self
- harm to others
- continuing deterioration WITHOUT treatment (lacks capacity)
