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Psychiatric emergencies > Syndromes > Flashcards

Syndromes Flashcards

1
Q

What is a dystonic reaction

A
  • Syndrome of sustained, often painful muscular spasms, producing repetitive, twisting movements, or abnormal postures
  • Develop following antipsychotic exposure

An extra pyramidal SE

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2
Q

RFs dystonic reaction

A
  • PMH + FH dystonia
  • Younger age
  • Liver failure
  • Severe schizophrenia
  • Use of high-potency antipsychotics…etc
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3
Q

When does acute dystonia happen

A

Occurs w/in 1w o commencing or rapidly ↑ antipsychotic

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4
Q

What are the symptoms and signs of acute dystonia

A

o Muscles of head + neck: torticollis, trismus, jaw opening, forceful posturing of tongue, blepharospasm, grimacing, oculogyric spasm (eyes rolled back in locked position), opisthotonus
o Laryngospasm
o Dysphasia

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5
Q

What is tardive dystonia

A

Similar to acute but occurs days-months following exposure

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6
Q

Treatment for dystonia

A
  • If severe: STOP antipsychotic
  • Emergency Rx w/ IM anticholinergic (e.g. benzatropine)
  • Consider switching to antipsychotic w/ low risk to cause EPSE (atypical antipsychotics)
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7
Q

What is neuroleptic malignant syndrome

A

TOO LITTLE DOPA

  • Rare life-threatening condition in pt’s taking anti-psychotic medications
  • May also occur in pt’s taking dopaminergic drugs (levodopa) in PD → when the drug is stopped or dose reduced*

*remember PD and schizophrenia are opposites on a spectrum (+ their treatments)

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8
Q

Aetiology neuroleptic malignant syndrome

A
  • Overtreatment w/ antipsychotics (e.g. increasing dose)
  • Stopping or reducing levodopa too quickly
  • other drug causes: parkinson’s drugs can cause it too (as well as being withdrawn – e.g. amantadine), antidepressants (e.g. venlafaxine), carbamazepine…etc
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9
Q

CFs neuroleptic malignant syndrome

A
  • Onset usually 10d of treatment or after ↑ dose
  • Pyrexia/fever, muscular rigidity, confusion, fluctuating consciousness
  • Autonomic dysfunction (as dopamine is a catecholamine): tachycardia, hypo/hypertension
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10
Q

ix neuroleptic malignant syndrome

A
  • Creatinine kinase ↑
  • FBC: leucocytosis (excess WBC)
  • LFTs deranged
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11
Q

Rx neuroleptic malignant syndrome

A
  • Stop antipsychotic/causative agent, monitor vital signs, IV fluids to prevent renal failure, cooling, dantrolene (muscle relaxant), bromocriptine (dopamine agonist)
  • Consider: BDZ’s
  • In parkinson’s to prevent neuroleptic malignant syndrome: slowly reduce PD dose if necessary (+ educate pt’s not to stop medications)
  • Rhabdomyolysis: hydration + alkalinisation w/ IV sodium bicarbonate (prevent renal failure)
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12
Q

Complications neuroleptic malignant syndrome

A
  • PE
  • Renal failure
  • Shock (due to low BP)
  • Rhabdomyolysis
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13
Q

How does rhabdomyolysis cause renal failure?

A

it causes myoglobin release → breakdown → products damage kidney cells

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14
Q

Define serotonin syndrome

A

Rare life-threatening complication of increased serotonin activity (e.g. w/ SSRI use)

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15
Q

Aetiology serotonin syndrome

A
  • SSRI
  • Amfetamines
  • MAOIs
  • TCAs
  • Lithium

Caused by overdose, drug combinations (e.g. over-the-counter) and therapeutic doses (rare)

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16
Q

Pathophysiology serotonin syndrome

A
  1. ↑ production serotonin
  2. ↑ release of stored serotonin: e.g. MDMA, cocaine…etc
  3. Reuptake inhibition (build up of serotonin): SSRIs, TCAs, SNRIs, MDMA…etc
  4. ↓ metabolism of serotonin: MAOIs, selegiline (MAOB-inhibitor used in parkinson’s)
17
Q

CFs serotonin syndrome

A
  • Psychiatric/neurological: agitation, confusion, hypomania, coma
  • Neuromuscular: myoclonus (twitches), rigidity, tremor + shiver, hyperrefleia, ataxia
  • Autonomic: hyperthermia/fever, GI upset (Diarrhoea), mydriasis, tachycardia, hyper/hypotension, sweating

Think MDMA

18
Q

DDx serotonin syndrome

A

• Infection (e.g. encephalitis), metabolic disturbance, substance abuse/withdrawal

19
Q

Ix serotonin syndrome

A
  • FBC, U+Es, LFTs, glucose, pH, biochem (calcium, magnesium, phosphate, anion gap)
  • CK (rhabdomyolysis)
  • drug toxicology screen
  • CXR (resp distress/aspiration)
  • ECG monitioring → prolonged QRS or QTc interval
20
Q

Rx serotonin syndrome

A
  • STOP causative agent
  • If OD: gastric lavage ± activated charcoal
  • IV access + fluids: correct dehydration + prevent rhabdomyolysis
  • BDZ: agitation, seizures…etc
  • Serotonin receptor antagonist (chlorpromazine or propranolol)
  • Antihypertensive (IV GTN) if persistent HTN
21
Q

Complications serotonin syndrome

A

• Rhabdomyolysis

22
Q

To summarise, serious consequences of antipsychotics are:

A

dystonic reactions + Neuroleptic malignant syndrome

23
Q

To summarise, serious consequences of SSRIs are:

A

serotonin syndrome

24
Q

Difference between Neuroleptic malignant syndrome and serotonin syndrome w/r to: Assoc. rx

A

NME: antipsychotics
SS: serotonergic

25
Q

Difference between Neuroleptic malignant syndrome and serotonin syndrome w/r to: Onset

A

NME: slow - days to weeks
SS: rapid

26
Q

Difference between Neuroleptic malignant syndrome and serotonin syndrome w/r to: progression

A

NME: Slow
SS: Rapid

27
Q

Difference between Neuroleptic malignant syndrome and serotonin syndrome w/r to: Muscle rigidity

A

NME: Severe
SS: Less severe

28
Q

Difference between Neuroleptic malignant syndrome and serotonin syndrome w/r to: Activity

A

NME: Bradykinesia
SS: Hyperkinesia

Psychiatric emergencies (3 decks)

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