ECT + Psych EMERGENCIES Flashcards
5 CRITERIA for MHA compulsory treatment
1) patient appears to have a mental illness
2) patient is at imminent risk of harming themselves or others
3) a gazetted facility is available for treatment
4) …….
5) this has been done though the least restrictive means possible
6 criteria for SAFE DISCHARGE
1) Medically stable
2) Psychiatrically stable
3) At no or minimal risk to self or others
4) Discharge destination organised
5) trial of home has been successful
6) follow-up organised
Mechanism of action of ECT
Probably a combination of:
• anti-convulsant effect of ECT
• restoration of physiological frontolimbic interactions (reduced limbic, enhanced prefrontal activity)
• increased and potent release of nerve growth factors
• increased release of 5-HT, NA, DA and prefrontal glutamate (similar to anti-depressants)
• hormonal changes
INDICATIONS for use of ECT
- Severe melancholic depression (esp w psychosis +/or catatonia - impressive results)
- psychotic depression
- Schizophrenia with comorbid severe depression
- Severe depression during:
- pregnancy (safer vs meds)
- puerperium (where a high risk of injury to the mother or baby is present)
• geriatric psychiatry (esp if can’t take med b/c of medical condition comorbidity - QTc prolongation etc)
- esp severe depression in elderly (excellent response)
• resistent Mania/schizoaffective/schizophrenia/psychosis
CONTRAINDICATIONS to ECT
Absolute C/I = raised ICP (e.g.: brain tumours, hydrocephaly)
Relative C/I:
- recent cerebrovascular accident (
SIDE EFFECTS of ECT
• COGNITIVE IMPAIRMENT
- Retrograde/anterograde amnesia (bilateral > unilateral)
- confusion in post-octal period
- persistent memory disturbance
- Lethargy
- Headaches - common in early treatment
- Muscle aches/MSK injury
- Nausea
NB: cognitive impairment worsened by concurrent use Lithium or MAOIs
- mania (easily relieved by further Rx)
- persistent seizures ( relieved by IV anti-convulsant e.g.: diazepam)
Factors effecting ECT threshold
Medications
- benzos increase threshold
- a/d + a/p lower threshold
M>F
Age
Electrode placement Bilat > unilat
number of ECTs
Markers of efficacious ECT dose
seizure onset fairly rapid
symmetrical & generalised
- tonic and then clonic phases
seizure duration (20-120 sec)
EEG: amplitude and degree of synchronicity between leads
good post-octal suppression
Marker of ECT sub threshold dose
substantial delay in actual seizure onset
tonic reaction, but no clonic movements
EEG: irregular, generally slow pattern with variable amplitude
brief (120 sec) seizures
Poor post-ictal suppression
Define: NEUROLEPTIC MALIGNANT SYNDROME
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Features common to NMS and serotonin syndrome
AUTONOMIC
- ↑ or labile BP
- ↑ HR
- ↑ RR
- ↑ temp ( >40ºC)
- diaphoresis
- ↑ salivation
NEURO/MSK
- ↑ tone
- confusion
- agitation
Distinguishing features of NMS (vs SS)?
AUTONOMIC
- normal pupils
- Normal or ↓ bowel sounds
CNS
- HYPOreflexic
- rigidity
Other
- ↑ CK
- ↑ WCC
Distinguishing features of SS ( vs NMS)
AUTONOMIC
- dilated pupils
- hyperactive bowel sounds
CNS
- HYPERreflexic
- clonus
Cause of NMS?
Dopamine antagonists (ie: anti-psychotic medication)
Cause of SS?
Serotonergic agents (SSRIs, SNRIs, TCA, MAOI, tramadol)
