Psychiatric emergencies

Question 1

Common features of acute confusion

Answer 1

rapid onset
Fluctuation
Impaired consciousness
Imapired recent and immediate memory
Disorientation
Perceptual disturbance, especially in visual or tactile modalities
Psychomotor disturbance
Altered sleep-wake cycle

Question 2

Common causes of acute confusion

Answer 2

Pain or discomfort (urinary retention, constiaption)
Hypoxia
Metabolic disorders (renal or liiver failure, acidosis rtc)
Infection
Cardiac causes
Neurological (head injury, subdural, CNS infection, post ictal)
Drugs (benzo, opiates, digoxin, steroids, anti PD drugs, anticholinergics, alcohol, GBL, ketamine.’.)
Alcohol or drug withdrawal

Question 3

Conservative management of delirious patient behaviour

Answer 3

treat underlying cause
Nurse in a well lit, quiet room with familiar nursing staff and if possible a family member. Effective communication, reorientation and reassurance.

Question 4

Sedation options for patients with delirium

Answer 4

Always start low and titrate up slowly.
Haloperidol 0.5-1mg PO bd licensed for agitation in the elderly, additional 4 hourly doses. Ideally do ECG first.
Lorazepam 0.25-1mg PO/IM every 2-4ht as needed (half dose in elderly), but benzos may exacerbate confusion in elderly
Diazepam 5-10mg PO (start at 2mg in elderly)
Avoid antipsychotics with PD or LBD
If neuroleptic naive, use very low doses of antipsychotics due to disk of EPSEs
Reassess sedation after 15-20min

Question 5

Rapid tranquilisation for acute disturbance

Answer 5

1. Attempt verbal and situational de escalation
2. Offer oral treatment. If on regular antipsychotic offer lorazepam 1-2mg or buccal midazolam 10-20mg, can repeat hourly. If not, possibly olanzapine 10mg, risperidone 1-2mg or haloperidol 5mg.
3. If refused or ineffective and significant risks consider IM lorazepam 1–2mg, promethazine 50mg, olanzapine 10mg, aripiprazole 9.75mg, or haloperidol 5mg, rep every 30-60min.
4. Consider IV treatment, diazepam 10mg over 5 min. (have flumazenil to hand in case resp depression)
5. Seek expert advice

Question 6

Early signs of alcohol withdrawal

Answer 6

Anxiety, restlessness, tremor, insomnia, sweating, tachycardia, ataxia and pyrexia. Consider using CIWA scale.

Question 7

Delirium tremens presentaton

Answer 7

Confusion, disorientation, labile mood and irritability, hallucinations, fleeting delusions (often very frightening)

Question 8

Korsakoff syndrome presentation

Answer 8

acute confusion, ataxia, nystagmus, ophthalmoplegia, possibly peripheral neuropathy. Don’t need all of these.

Question 9

Alcohol withdrawal risk level high if…

Answer 9

drink over 30 units per day
Score >30 on severity of alcohol dependence questionnaire
History of epilepsy, withdrawal seizures or DT
Also withdrawing from benzos
Significant psychiatric or physical comorbidities
Lower threshold of vulnerable group
Any signs of DT or Korsakoffs

Question 10

Treatment of alcohol withdrawal

Answer 10

Chlordiazepoxide or diazepam, Pabrinex as prophylaxis for Wernicke’s. If IV agent needed, use diazepam.

Question 11

Neuroleptic malignant syndrome in brief

Answer 11

rare, life threatening, idiosyncratic reaction to antipsychotics and other medication.
Characterized by fever, muscular rigidity, altered mental state and autonomic dysfunction
Reauire urgent transfer to acute medical services.

Question 12

Prevalence of NMS

Answer 12

0.07-0.2%, but with mortality of 5-20%

Question 13

Morbidity in NMS

Answer 13

rhabdomyolysis, aspiration pneumonia, renal failure, seizures, arrhythmias, DIC, respiratory failure, worsening of primary psychiatric disorder (due to withdrawing the antipsychotics)

Question 14

Symptoms and signs of neuroleptic malignant syndrome

Answer 14

Hyperthermia (>38°)
Muscle rigidity
Confusion/agotation/altered level of consciousness
Tachycardia
Tachypneoa
Hyper/hypotension
Tremor
Incontinence/retention/obstruftjon
Raise CK
Leucocytosis
Metabolic acidosis

Question 15

Differential diagnoses for NMS

Answer 15

Catatonia
Malignant hyperthermia
Encephalitis or meningitis
Heat exhaustion
Acute dystonia
Serotonergic syndrome
Other drug toxicity
Rhabdomyolysis
Sepsis
Tetanus
Phaeochromocytoma

Question 16

Management of NMS

Answer 16

Stop any causative agents, or restart anti Parkinson drugs
Support w O2, IV fluids, reduce temperature, hydration and alkalinisation of urine w IV NaHCO3 to prevent renal failure
Reduce rigidity (-dantrolene, lorazepam, bromocriptine…)

Question 17

Prognosis of NMS

Answer 17

May last 7-10 days after stopping oral antipsychotics, and up to 21 after depot
In absence of rhabdomyolysis, renal failure or aspiration pneumonia and with good supportive care then prognosis is good.

Question 18

Drugs which can cause NMS

Answer 18

Antipsychotics - all of the big names. Rarely clozapine or quetiapine
Withdrawal from anti-parkinsonian agents
Antidepressants - clomipramine, venlafaxine…
Other: Withdrawal from carbemazepine, ganciclovir, lithium, some random others

Question 19

Assessing suicide after an act of self harm - questions

Answer 19

Current mood and mood at time of act?
Forward planning, final acts, notes?
Precautions against being discorverdd?
What was going through their mind at time of act?
Did they mean to die?
Views on having survived?
Feelings now that they wish to harm themselves? Any plans?

Question 20

Principles of the mental capacity act

Answer 20

1. person is assumed to have capacity
2. All steps should be taken to enable person to make a decision
3. Person is allowed to make an unwise decision
4. Decision made unndef the act must be done in the persons best interests
5. Action must be taken in the way which is least restrictive

Question 21

Lacking capacity

Answer 21

Due to permanent or temporary impairment in functioning of mind unable to:
Understand the information relevant to the decision
Retain that information for a sufficient period to make the decision
Weigh the information as part of decision making
Communicate their decision

This is a judgement made on the balance of probabilities

Question 22

Using common law in emergency sotuations

Answer 22

Allow medical practitioners to act in patients best interests in emergencies when they are unable to give consent. And you can detain a patient pending assessment under common law, essentially if you are unsure about their capacity. But does have to be in concordance with patients wishes

Question 23

Paracetamol overdose treatment

Answer 23

Four hour blood paracetamol levels check to see if above treatment line on the nomogram
If above need treatment with NAC - all ingestions >75mg/kg are a significant overdose
Activated charcoal can be used up to 1 hour post ingestion
Also need to check clotting and LFTs
If at 4 hours:
- paracetamol is below 10
- INR is 1.3 or less
-ALT is normal
- AND patient has no symptoms of liver damage
Then patient does not need treatment.

Question 24

SAD PERSONS score

Answer 24

Risk assessing score post self-harm/suicide

Sex = male 1
Age <19 or >45 1
Depressed symptoms 2
Past psychiatric history or suicide attempts 1
ETOH/drug use history 1
Rational thought loss 2
Separated/divorced/widowed/signif sickness 1
Organized plan or serious attempt 2
No social support 1
Stated intent (or ambivalence) 2

If <6 may discharge home if someone to care for them, FU within 1 day, and create safety plan
>8 admit

Question 25

Risk factors for deliberate self harm

Answer 25

Female gender
Previous deliberate self harm
Self injury as method of harm especially if serious
Age 15-24
Usually impulsive
History of loss of parent in early life
History of emotional, physical or sexual abuse

Question 26

Acute first episode psychosis investigations

Answer 26

Obs
FBC
U&Es
LFTs
TFTs
Calcium
Blood glucose
Haematinics
CRP
Urine dip for drugs screen

Question 27

Differential diagnoses for delirium

Answer 27

I WATCH DEATH
Infection
Withdrawal
Acute metabolic
Trauma
Central nervous system pathology
Hypoxia
Deficiencies
Endocrine
Acute vascular
Toxins
heavy metals