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PSYCH Flashcards

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1
Q

What is the first-line medication for undifferentiated severely agitated patients requiring rapid tranquilization?

A

Benzodiazepine (lorazepam) alone or with first-generation antipsychotic (haloperidol)

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2
Q

Name 3 positive predictors of violence in patients.

A

Male gender, prior history of violence, drug or alcohol abuse

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3
Q

What are the 3 main categories of patient problems associated with violence?

A

Psychiatric, street drug abuse/withdrawal, organic (DIMES), situational/antisocial behavior

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4
Q

List 4 essential elements of physical restraint.

A

Appropriate indication, follow hospital protocol with restraint team, secure restraints to bed frame (not side rails), close observation for neurovascular injury

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5
Q

What are the 3 medications used for chemical restraints and their typical doses?

A

Haloperidol 2.5-5mg IM/IV, Lorazepam 2mg IM/IV, Ketamine 1-2mg/kg IV or 4-5mg/kg IM

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6
Q

What is the FORTY mnemonic for distinguishing organic from functional causes of violent behavior?

A

Family history, Onset <40 (more likely functional), Recent trauma/drugs/stressors, Toxidrome, Y = Why presenting now?

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7
Q

Name 3 ED factors that impair physician-patient relationships.

A

Time constraints/interruptions, lack of privacy/comfort, long waiting times/crowding

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8
Q

What does the SALTER V mnemonic stand for in difficult patient communication?

A

Structure interview, Actively listen, Limit setting, Take time out, Expectations, Redirect to main concern, Validate emotions

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9
Q

List 4 behaviors suggesting impending violence.

A

Loud speech, tense posturing/angry demeanor, pacing, aggressive behavior

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10
Q

What are 4 key elements of verbal de-escalation?

A

Safe space/distance, non-confrontational posture, listen carefully, acknowledge frustration

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11
Q

What are the 5 basic steps in crisis intervention (SAFER-R model)?

A

Stabilize, Acknowledge, Facilitate, Encourage, Restore/Refer

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12
Q

Name 6 organic diseases that can cause violence.

A

Delirium, dementia, trauma, CNS infection, seizure, neoplasm

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13
Q

What are 4 drug categories that can cause violence?

A

Alcohol (intoxication/withdrawal), amphetamines, cocaine, sedative-hypnotics, anticholinergics

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14
Q

List 3 primary prevention strategies for violence in the ED.

A

Minimize frustration, calm/efficient visits, see violent patients sooner, police/security presence

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15
Q

What are contraindications to antipsychotics in violent patients?

A

Alcohol/benzodiazepine withdrawal, seizure disorders, pregnancy, phencyclidine overdose

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16
Q

What is the preferred positioning for physical restraints?

A

Supine with head elevated 30 degrees (never prone)

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17
Q

Name the 4 difficult patient behavior types described in Rosen’s.

A

Dependent clinger, entitled demander, manipulative help rejector, self-destructive denier

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18
Q

What is the key management approach for the undifferentiated agitated patient?

A

Consider organic causes first, use benzodiazepines as safest choice

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19
Q

List 3 tools for managing negative physician-patient reactions.

A

Maintain appropriate emotional distance, understand negative behavior as symptom, avoid overly stereotyping

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20
Q

What is the maximum time restraints should remain in place?

A

Remove as soon as safe, usually once adequate chemical sedation achieved

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21
Q

What percentage of substance abusers will ultimately die by suicide?

A

10-15% of suicide attempters will ultimately die by suicide

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22
Q

Name 5 red flags for prescription drug misuse.

A

Repeated visits for same complaints, rapid dose escalation, unusual allergies, demands for specific agents/doses, frequent ER visits

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23
Q

What is the CRAFFT screening tool for adolescent substance abuse?

A

Car (ridden with impaired driver), Relax (use to relax), Alone (use alone), Forget (memory problems), Family/Friends (tell you to cut down), Trouble (gotten into trouble)

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24
Q

What makes cocaine and ethanol combination dangerous?

A

Forms cocaethylene - longer half-life, more hepatotoxic, enhances and magnifies cocaine effects

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25
What is levamisole and how does it present?
Cocaine adulterant causing life-threatening agranulocytosis, leukoencephalopathy, and cutaneous vasculitides
26
Name 4 common club drugs.
MDMA (ecstasy), cocaine, PCP, ketamine, GHB, LSD
27
List 5 complications of drug abuse affecting different organ systems.
Endocarditis (cardiac), stroke/seizures (neuro), HIV/Hep C (infectious), anxiety/depression (psychiatric), trauma
28
What are 4 strategies for managing prescription drug misuse?
Risk assessment/documentation, optimize alternative treatments, treatment agreement, regular follow-up with same provider
29
What percentage of street drug samples lack the alleged drug?
Up to 50% of street samples lack the alleged drug
30
Name 3 contraindications to controlled substances in suspected drug misuse.
Current untreated addiction, poorly controlled psychiatric illness, erratic follow-up
31
What is the most common recreational drug in Americans?
Alcohol (third leading cause of preventable death)
32
List 4 physical examination findings suggesting substance abuse.
Track marks, abnormal pupils, altered mental status, abnormal vital signs
33
What are the Five A's for follow-up assessment of chronic pain patients on opioids?
Analgesia, Activities of daily living, Addiction, Adverse effects, Adherence
34
Name 3 synthetic substances commonly abused by adolescents.
Bath salts (synthetic cathinones), Spice/K2 (synthetic cannabinoids), dextromethorphan
35
What percentage of adolescents have tried illicit drugs by adulthood?
Almost half will have tried an illicit drug, over 80% will have used alcohol
36
List 3 high-risk substance combinations that can cause serotonin syndrome.
Sympathomimetics + SSRIs, amphetamines + MAOIs, multiple serotonergic drugs
37
What is the treatment approach for prescription drug misuse in the ED?
Focus on specific medical concern, optimize non-controlled therapies, defer to chronic pain clinics
38
Name 4 environmental risk factors for substance abuse.
Job/financial loss, social isolation, access to substances, local suicide clusters
39
What are key components of a substance abuse treatment agreement?
Same pharmacy, regular provider follow-up, treatment goals, monitoring plan, drug testing
40
List 3 legal highs commonly obtained online.
Synthetic cathinones, synthetic cannabinoids, novel psychoactive substances
41
What type of kinetics does alcohol elimination follow?
Zero-order kinetics (constant rate) for lower levels, first-order for higher levels in chronic alcoholics
42
What are the 3 main elimination pathways for alcohol?
Lungs, urine, and sweat
43
Define hazardous drinking amounts for men and women.
Men: >14 drinks/week or >4/day; Women/elderly: >7 drinks/week or >3/day
44
What is the AUDIT-C screening tool cutoff scores?
Women: ≥3; Men: ≥4
45
When do minor vs major alcohol withdrawal symptoms peak?
Minor: peaks at 24-36 hours; Major: peaks at 50 hours (up to 5 days)
46
What are the risk factors for delirium tremens?
Sustained drinking history, previous DTs, age >30, concurrent illness, withdrawal with elevated alcohol level
47
What is first-line treatment for alcohol withdrawal?
Benzodiazepines (diazepam 5-10mg IV or lorazepam 2-4mg IV)
48
List 6 ways alcohol can cause seizures.
Withdrawal, metabolic disorder (hypoglycemia), trauma, precipitation in epileptics, lowering seizure threshold, increasing susceptibility to CNS infections
49
What are the key features of alcoholic ketoacidosis?
Malnourished alcoholic, recent binge, nausea/vomiting, elevated anion gap, ketonuria, glucose <13 mmol/L (90%)
50
How do you treat alcoholic ketoacidosis?
Dextrose + saline, thiamine 100mg IV/IM, correct K+/PO4/Mg2+
51
What is Wernicke's encephalopathy triad?
Diplopia, ataxia, encephalopathy (only 1/3 have complete triad)
52
What is the treatment for Wernicke's encephalopathy?
Thiamine 500mg IV over 30 minutes TID x 2 days, then 250mg daily x 5 days
53
Name 6 contributing factors to upper GI bleeding in alcoholics.
Portal hypertension/varices, gastritis/esophagitis, GI cancers, hemostasis disorders, smoking/NSAIDs, Mallory-Weiss tears
54
List 8 metabolic effects of chronic alcohol use.
Hypoglycemia, hypokalemia, hypomagnesemia, hypophosphatemia, hyponatremia, hypocalcemia, low testosterone, insulin resistance
55
What are 4 dangerous alcohol-drug interactions?
Increased acetaminophen toxicity, enhanced CNS depression with sedatives, prolonged cocaine intoxication, disulfiram-like reaction with metronidazole
56
When do alcohol withdrawal seizures typically occur?
6-48 hours after cessation, 60% have multiple seizures within 6 hours
57
What is the management of alcohol withdrawal seizures?
Supportive care only, benzodiazepines for status epilepticus (phenytoin is ineffective)
58
What percentage of withdrawal seizures progress to delirium tremens if untreated?
Nearly one-third (33%)
59
What supportive care is essential in severe alcohol withdrawal?
Thiamine 100mg + glucose daily, fluid/electrolyte replacement, multivitamins, adequate calories
60
What is the difference between Wernicke's and Korsakoff's?
Wernicke's = acute thiamine deficiency; Korsakoff's = chronic form (amnestic syndrome)
61
What percentage of Americans will meet criteria for a mood disorder in their lifetime?
Estimated 21% will have a mood disorder
62
Name the top 3 risk factors for suicide.
Male gender, prior suicide attempt, psychiatric disorders (especially depression + anxiety OR = 17)
63
List 5 additional risk factors for adolescent suicide.
Sexual orientation (LGBTQ), sedentary activities, weight concerns, sexual health issues, exposure to violence
64
What is the SAD PERSONS scale and why is it not recommended?
Sex, Age, Depression, Previous attempt, Ethanol, Rational thinking loss, Social supports, Organized plan, No spouse, Sickness. Not sensitive enough to be clinically useful.
65
Name 4 targeted investigations for suicidal patients.
Pregnancy test, drug screen, alcohol level, head CT (if altered mental status)
66
What are 3 protective factors against suicide?
Social support/family connectedness, pregnancy/parenthood, religiosity
67
What percentage of suicide completers have no prior attempt history?
Up to 80% die on first known attempt
68
List the 5 components of suicide inquiry.
Ideation (frequency, intensity, duration), Plan (timing, location, lethality), Behaviors (past attempts), Intent (expects to carry out plan), Ambivalence (reasons to die vs live)
69
What demographic has the highest suicide risk?
White males, American Indian/Alaskan Native, adolescents and elderly
70
Name 5 psychiatric conditions with high suicide risk.
Depression, bipolar disorder, schizophrenia, anxiety disorders, PTSD
71
What are environmental risk factors for suicide?
Job/financial loss, social isolation, access to lethal means (guns), recent loss/incarceration
72
How does alcohol relate to suicide risk?
2-18% suicide rate in alcoholics, 90% are men, 30% of all suicides have alcohol in system
73
What defines low-risk suicidal patients who can be discharged?
Denial of suicidal thoughts/plan, mild sadness, no recent high-lethality attempts, good support, accepting help
74
What is required for discharged suicidal patients?
Education and safety planning in ED, early mental health follow-up, safe environment without guns/toxic medications
75
What is suicide by cop?
When suicidal individual intentionally provokes police to shoot in self-defense
76
List 4 criteria for hospitalization of suicidal patients.
Actively suicidal, dangerous to others, severe mental debilitation preventing self-care, first psychotic episode
77
What is the most important predictor of future suicide attempts?
Prior suicide attempt (10-15% will ultimately die by suicide)
78
How do anxiety disorders affect suicide risk?
Double the risk of suicide attempts; combination with depression greatly increases risk (OR=17)
79
What percentage of suicidal individuals see a physician before death?
Many see a physician shortly before their death
80
What should routine screening labs include for suicidal patients?
Routine labs provide little value - evaluation should be directed at specific concerning signs/symptoms
81
What are the 3 neurotransmitters implicated in depression?
Serotonin, norepinephrine, dopamine (low levels)
82
What is the DSM-5 criteria timeframe for major depressive episode?
At least 5 symptoms for minimum 2 weeks, including depressed mood or anhedonia
83
What is the SIGE CAPS mnemonic for depression symptoms?
Sleep, Interest (anhedonia), Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidal ideation
84
How is seasonal affective disorder treated?
Phototherapy
85
What defines persistent depressive disorder (dysthymia)?
Depressed mood most days for ≥2 years with 2+ additional symptoms
86
What's the difference between Bipolar I and II?
Bipolar I: ≥1 manic episode; Bipolar II: hypomanic episode + ≥1 major depressive episode
87
What is the GST PAID mnemonic for mania?
Grandiosity, Sleep (decreased need), Talkative, Pleasure (risky activities), Activity increased, Ideas (flight of), Distractibility
88
List 8 medical conditions that can cause depression.
Parkinson's, CAD, MI, stroke, renal disease, AIDS, connective tissue diseases, hyperthyroidism
89
What medications can cause depression?
Antihypertensives, anticonvulsants, hormones, alcohol, sedatives, hypnotics, anxiolytics
90
What is first-line treatment for depression?
SSRI/SNRI plus psychotherapy (e.g., citalopram 20mg daily)
91
What is first-line treatment for bipolar disorder?
Mood stabilizer (lithium, valproic acid, carbamazepine) + second-generation antipsychotic
92
What percentage of bipolar patients exhibit suicidal behavior?
Up to 80%, with half attempting suicide
93
What are the 4 criteria for psychiatric hospitalization?
Actively suicidal, dangerous to others, severe mental debilitation preventing self-care, first psychotic episode
94
How long must cyclothymic disorder symptoms be present?
Chronic mood swings for at least 2 years, present ≥50% of time, cannot be symptom-free >2 months
95
What defines a manic episode duration?
Abnormally elevated/irritable mood ≥1 week (or any duration if hospitalization needed)
96
Which mood episodes carry highest suicide risk in bipolar disorder?
Depressed or mixed episodes, especially with severe symptoms and hopelessness
97
What percentage of ED visits are for psychiatric reasons?
13% in 2007 (increased from 5% in 2000)
98
Name medications that can cause mania.
Antibiotics, steroids, cocaine, PCP, hallucinogens, amphetamines
99
What is the key to differentiating depression from dementia in elderly?
Depression often responds dramatically to treatment
100
How should mood disorder patients always be assessed?
For suicide potential - must be questioned about suicidal thoughts
101
What are the positive symptoms of schizophrenia?
Hallucinations (AVOGS - auditory, visual, olfactory, gustatory, somatic), delusions, disorganization
102
What are the negative symptoms of schizophrenia?
Blunted affect, emotional withdrawal, social withdrawal, poor rapport, difficulty with abstract thinking
103
List 4 rapid tranquilization agents and doses.
Midazolam 2.5-5mg IM, Lorazepam 1-2mg PO/IM, Haloperidol 5-10mg PO/IM, Ziprasidone 10-20mg PO/IM
104
Name 6 factors suggesting medical cause of psychosis.
New onset, acute mental status change, age >50, recent fluctuation, non-auditory hallucinations, abnormal vitals
105
How do you differentiate organic from functional psychosis?
Organic: new onset, acute change, age >50, visual hallucinations, abnormal vitals; Functional: auditory hallucinations, family history, oriented
106
What is brief psychotic disorder?
Sudden onset psychotic symptoms in response to stress, lasting days to 1 month
107
What is schizophreniform disorder?
Symptoms similar to schizophrenia lasting 1-6 months (1/3 recover, 2/3 develop schizophrenia)
108
What is schizoaffective disorder?
Schizophrenia symptoms persisting >2 weeks in absence of prominent mood episode
109
What is delusional disorder?
One or more delusions >1 month, schizophrenia criteria not met, function not severely impaired
110
List 8 medical disorders causing psychosis (mnemonic: PSYCHNOSIS).
Postpartum, Sarcoid, thYroid, Calcium/Carbon high, HypoNa/O2/glycemia, SLE, encephalItis, Substrate deficiencies
111
Name 10 drugs causing acute psychosis.
Antihistamines, cocaine, cannabis, corticosteroids, tranquilizers, ETOH, propranolol, sedatives, phenytoin, opioids
112
What's the difference between typical and atypical antipsychotics?
Typical: postsynaptic D2 blockade, higher EPS risk; Atypical: loose D2 binding, multiple receptor activities, lower EPS risk
113
List 8 adverse effects of neuroleptics.
QTc prolongation, EPS, tardive dyskinesia, anticholinergic effects, NMS, orthostatic hypotension, sedation, metabolic syndrome
114
What is neuroleptic malignant syndrome?
Fever, rigidity, altered mental status, autonomic instability, elevated CPK - can occur with typical and atypical antipsychotics
115
What are the 4 indications for hospitalization of psychotic patients?
Actively suicidal, dangerous to others, severe mental debilitation preventing self-care, first psychotic episode
116
What is Ganser's syndrome?
Factitious disorder (prison psychosis) - person behaves as though they have psychotic disorder
117
What percentage of schizophrenia risk is attributed to genetic factors?
80% of variation attributed to genetic factors
118
What neurotransmitter pathways are implicated in schizophrenia?
Dopaminergic, serotonergic, cholinergic, and glutamatergic pathways
119
What is the most common adverse effect of neuroleptics?
Dystonia (1-5% of patients) - treat with anticholinergics (Benadryl 25-50mg IV or Cogentin 1-2mg IV)
120
What special monitoring does clozapine require?
Regular blood cell count monitoring due to 1% risk of granulocytopenia/agranulocytosis

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