Psychiatric Eval, Mgmt, DoA

Question 1

Describe common medical complaints that may be related to organic psychiatric illness?

Answer 1

• Palpitations
• Chest pain, tightness
• SOB
• Abd pain, N/V
• HA
• Syncope
• Seizures
• Paresthesia
• Throat tightness
• Tremors
• Fear/panic

Question 2

Name several organic causes of psychaitric illness, and several inorganic causes

Answer 2

• Organic
  
  • Drug toxicity/intox
  • Withdrawal
  • Head trauma
  • Encephalopathy
  • Hypoglycemia
  • Metabolic/electrolyte derrangement
  • Hypoxia
  • Organ failure
  • Postictal
  • Hyper/hypothyroid
• Inorganic
  
  • Primary psychiatric illness
    
    • Depression, psychosis, anxiety/panic, bipolar, schizophrenia
  • Behavioral disturbance
    
    • Autism
    • Dementia
    • Cognitive disability

Question 3

Name your red flags that a patient’s psychiatric illness has an organic root cause

Answer 3

• Rapid onset of new psych symptoms
• New onset > 40 years old
• Any onset > 65 years old
• Delirium present
• Focal neuro deficit
• Presence of toxidrome
• Traumatic injury/illness evident
• Abnormal vitals: Fever, tachycardia, hotn, hypoxia, tachypnea
• Visual vs auditory hallucinations
  
  • Visual tend to be a/w delirium, whereas auditory tend to be a/w psychosis

Question 4

What is your diagnostic workup for acute psychiatric illness?

What are your key pharmacologic considerations re: poisonings, adverse drug effects, and OTC meds?

Answer 4

• Dx workup
  
  • None if inorganic/primary psychiatric
  • Based on history and physical
  • Rule out underlying medical causes that require tx
  • Consider differentials beyond the psych symptom
• Poisonings
  
  • Dilantin
  • Digoxin
  • TCAs
• ADEs
  
  • Depakote
  • Prednisone
  • SSRI/SNRI in bipolar patient
  • Phentermine
• OTC meds
  
  • Pseudoephedrine
  • Diphenhydramine

Question 5

1st Gen Antipsychotic: Haldol

• Route:
• MOA:
• AEs:
• Benefits:

2nd Gen Antipsychotic: Olanzapine, Ziprasidone, Aripiprazole, Risperidone (PO), Quetiapine (PO)

• MOA:
• Efficacy:
• Safety profile:

Answer 5

• Haldol
  
  • Route: PO, IM, IV
  • MOA: Selective D2 receptor antagonist
  • AEs: Prolonged QT with IV admin, high doses; EPS side effects
  • Benefits: Low risk of resp depression with other CNS depressants
• 2nd Gen Antipsychotics
  
  • MOA: D2 and Serotonin 2A receptor Antagonists
  • Efficacy: Similar to Haldol, not inferior
  • Safety profile: Not as well studied as haldol
    
    • lower risk of prolonged QT, EPS
    • Resp depression can occur with other CNS depressants

Question 6

Benzodiazepines: Loraze, diaze, midazo

• Route:
• MOA:
• AEs:
• DDIs:
• Notes

Ketamine:

• Indication:
• Advantages:
• Disadvantages:
• Dose:

Answer 6

• BZDs
  
  • Route: IV, IM, PO
  • MOA: GABA receptor agonist, induces sedation
  • AEs: Resp depression, hotn
  • DDIs: EtOH intox, CNS depressants
  • Notes:
    
    • Not used as monotherapy for psychosis
    • Avoid in elderly
• Ketamine
  
  • Indication: excited delirium syndrome
  • Advantages: rapid onset, no respiratory depression
  • Disadvantages: may require rescue sedation, emergence phenomenon
  • Dose: 5mg/kg IM

Question 7

Dexmedetomidine:

• MOA
• Indication
• Advantages
• Disadvantages

Answer 7

• MOA: Selective alpha-2 agonist
• Indication: Sedation, delirium, severe EtOH withdrawal
• Advantages: Low risk of resp depression, less delirium induction
• Disadvantages: Hotn, bradycardia, hypertension

Question 8

Your patient abuses drugs by the following routes, what are your route-specific medical considerations/complications?

• IV
• Nasal
• Rectal

Answer 8

• IV
  
  • Infxn: bacteremia, endocarditis, cellulitis, abscess (cutaneous, spinal cord, brain, psoas muscle), osteo
  • Retained foreign body
  • DVT, arterial thrombosis, limb ischemia
  • Poor venous access
• Nasal
  
  • Loss of smell
  • Nosebleeds
  • Perf of nasal septum/soft palate
  • Dysphagia
  • Lung dz
• Rectal
  
  • OD - bypasses liver/first pass
  • Necrosis
  • Inestinal ischemia, perforation
  • Fecal incontinence

Question 9

Describe your medical concerns for each of the following class of drug intoxication/abuse:

• Opioids
• Sympathomimetics
• EtOH
• Hallucinogens

Answer 9

• Opioids
  
  • Life threatening resp/CNS depression
• Sympathomimetics
  
  • Hyperthermia, tachycardia, htn, diaphoresis
  • CHF, MI, arrhythmia, vasospasm, stroke
  • Dehydration, rhabdo, renal failure
  • Violence, psychosis
  • Loss of pain perception
• EtOH
  
  • Life threatening resp/CNS depression
  • Delirium, agitation
  • Starvation ketoacidosis
  • Wenicke vs hepatic encephalopathy
  • Delirium tremens/severe withdrawal
  • Occult injury
• Hallucinogens
  
  • Psychosis and agitation
  • Potentially permament psychosis

Question 10

Describe your dx workup for a patient who presents severely intoxicated

Answer 10

• None necessary if NO medical issues and patient admits to drug use
  
  • Tox screening usually unnecessary
• If clinically indicated, workup is directed by age, comorbidites, likely complications
• Possible scenarios:
  
  • Cardiac: EKG, troponin, BNP, monitoring
  • Renal: BMP, CK, UA
  • Intentional OD: ASA/APAP
  • Infxn: Wound cultures, blood cultures
  • Female: urine preg
  • IVDA: CXR, PE screen
  • Trauma: imaging