14. Psychiatric emergencies

Question 1

Outline neuroleptic malignant syndrome (NMS)

Answer 1

Pts taking antipsychotic meds (dopamine antagonist)

It has been proposed that blockade of D2-like (D2, D3 and D4) receptors induce massive glutamate release, generating catatonia, neurotoxicity and myotoxicity.

S+S = fever, muscle rigidity, delirium, autonomic instability (tachy, fluctuating BP), confusion

***death usually to rhabdomyolysis, renal failure, seizures

Ix = markedly raised serum CK, raised WCC, deranged LFTs

Mx = stop causative factor, lorazepam (for acute behavioural disturbance + muscle relaxant), fluids, cooling blankets, O2, Na bicarb (rhabdomyolysis), haemodialysis if renal failure from rhabdo

Comp = PE, renal failure, shock

Question 2

Outline acute alcohol withdrawal + delirium tremens

Answer 2

Withdrawal delirium develops between 24h-1w after alcohol cessation

S+S =

• dehydration
• electrolyte disturbance
• cognitive impairment
• vivid perceptual abnormalities (hallucination/illusions)
• paranoid delusions
• marked tremor
• autonomic arousal (tachy, fever, pupil dilatation, sweating)

Admit = monitor vitals, benzo (chlordiazepoxide), haloperidol/diazepam for psychosis, IV pabrinex (vitamins B1, B2, B6, nicotinamide, vitamin C and glucose)

Question 3

Outline Wernicke’s encephalopathy

Answer 3

Thiamine (vit B1) def (decreased intake/absorption)=
- Acute neurological triad of ophthalmoparesis:
1) confusion
2) wide based gait ataxia
3) ophthalmoplegia (nystagmus, conjugate gaze, bilateral lateral rectus palsies)
Additional = decrease consciousness, memory disturbance, peripheral neuropathy, hypotension, hypothermia, ptosis

• due to haemorrhage in the midbrain

Mx = high dose IV/IM thiamine over 1w, then oral until no risk

Comp = Korsakoff syndrome (hypothalamic damage and cerebral atropy due to repeated thiamine def) - short-term mem loss, inability to remember recent events, making-up info, hallucination

Question 4

Outline acute dystonia

Answer 4

SE of antipsychotics = involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx

Mx = stop antipsychotic, IM/IV procyclidine continue for 1-2d, consider long-term as prophylactic

Question 5

Outline lithium toxicity

Answer 5

S+S = N+V, course tremor, ataxia, muscle weakness, apathy
- severe: nystagmus, dysarthria, hyperreflexia, oliguria, hypotension, convulsions, coma

Normal level on Tx = 0.6-1.2 mEq/L

• Gastric lavage
• Dialysis
• Furosemide

Question 6

Outline Clozapine-induced agranulocytosis

Answer 6

Severe and dangerous leukopenia (lowered white blood cell count)

S+S = initially manifest as a local infection with sore throat, leucoplakia, erythema, and ulceration of the pharynx

Mx = stop antipsychotic, contact consultant haematologist, prophylactic Abx, lithium (increase WCC) and granulocyte colony stimulating factor