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Flashcards in Psychiatric Emergencies Deck (69):
1

1. Risk Factors associated with violence? 3

2. Signs of impending violence? 6

1. Factors associated with violence**:
-Male gender
-History of violence
-Drug or alcohol abuse

2. Signs of impending violence:
-Provocative behavior
-Angry demeanor
-Loud, aggressive speech
-Tense posturing
-Frequently changing body position
-Aggressive acts

2

Remove patient from contact w/ provocative patients
Expedite evaluation* (move them to the head of the line)

Verbal techniques:
11

1. Address violence directly— “You look angry.”
2. Set limits—inform the patient violence and abuse cannot be tolerated
3. Do not be provocative—keep hands relaxed/DO NOT stare at the patient
4. Be honest and straightforward—DO NOT LIE
5. Calm and soothing tone of voice
6. Concise, simple language!
7. Offer choices and optimism—patients feel empowered if they have some choice
8. Stand at least one arm's length away
9. Identify feelings and desires— “What are you hoping for?”
10. Take all threats seriously
11. Protect yourself***

3

If verbal techniques are not working and escalation occurs summon help!!!

Physical restraints:
1. advantages?
2. Remove when?

3. Indications? 4

1. Use can be humane and effective, facilitating diagnosis and treatment
2. Remove as soon as possible, usually when adequate chemical restraint is achieved

3. Indications:
-Imminent harm to others
-Imminent harm to self (patient)
-Significant disruption of important treatment or damage to environment
-Continuation of effective, ongoing behavior treatment plan

4

Usually a protocol [make sure accessible!]
1. Should be a ___ person (at least) restraint team
2. Not to include who?
3. If female patient—one member needs to be ?

4. Once patient is restrained needs to monitored closely: 3

DOCUMENTATION why physical restraints required

1. 5

2. the provider so as to retain provider-patient relationship

3.female

4.
-Position changed
-Respiration
-Avoid aspiration

5

Three classes of meds used:

1. Benzodiazepines

2. First generation antipsychotics. Haloperidol

3. Second generation antipsychotics: clozapine

6

Benzodiazepines
1. Preferred when?
2. Agents? 2
3. Can cause what? So monitor careully
4. Can be used in combo with what?

1. Preferred when sedating patients when agitated from unknown cause

2. Agents:
-Lorazepam (PO, IM , IV)‏
-Midazolam (PO, IM IV); shorter half-life

3. Can cause respiratory depression—must be monitored closely!!

4. Can be used with first generation antipsychotics

7

First Generation Antipsychotics
1. Agents? 2
2. Both cause?
3. Avoid? 6

1. Agents:
-Haloperidal (PO, IM**)‏
-Droperidol (IM,IV) [Has black box warning**]

2. Both cause QT prolongation w/ potential for causing dysrhythmias (Torsade de Pointes)‏

3. Avoid:
-Cases of alcohol withdrawal
-Benzodiazepine withdrawal
-Other withdrawal symptoms
-Anticholinergic toxicity
-Patients w/ seizures
-Pregnant and lactating females

8

Second Generation Antipsychotics
1. Agents? 3
2. Advantages? 2
3. Disadvantages?

1. Agents:
-Olanzapine (Zyprexa)‏
-Risperidone (Risperdal)‏
-Ziprasidone (Geodon)‏

2. Less sedation & fewer extrapyramidal side effects

3. Less experience using them so benzodiazepines and first generation antipsychotics first choice

9

1. For severely violent patients requiring IMMEDIATE sedation?

2. For patients with agitation from drug intoxication?

3. For patients with undifferentiated agitation?

4. For agitated patients with a KNOWN psychiatric disorder?

5. Some patients may have paradoxical reactions—then?

1. first generation AP or/+ Benzodiazepine

2. benzodiazepine

3. benzodiazepines preferred, but first generation AP can be used

4. first generation AP or second generation AP

5. an agent from a different class should be used

10

Legal considerations?

What needs to be considered and documented? 4

1. Having a coworker record they agree w/ the assessment and treatment is powerful supporting documentation

2. Reasons for the clinician to restrain a patient need to be clearly documented

3. When a provider restrains a patient (physically or chemically THEY become RESPONSIBLE for the well-being of the patient!!

4. Duty to Warn is a legal concept—present in some locations

11

Post-Restraint Medical Evaluation
4

1. Complete set of vital signs including a pulse ox

2. Thorough mental status and neuro exams

3. Rapid blood glucose determination

4. RULE OUT acute medical condition

12

Acute AIDS Encephalopathy
1. Presentation? 2
2. What MUST you do?
3. Most common etiologies? 5

1. Presentation:
-Change in mental status
-Abnormal neurologic exam

2. MUST determine the degree of immunosuppression!

3. Most common etiologies:
-Toxoplasmosis encephalitis
-Primary CNS lymphoma
-Progressive multifocal leukoencephalopathy
-HIV encephalopathy
-CMV encephalitis

13

HIV-Infected Patients w/ CNS Lesions
The degree of immunosuppression in the host:

1. CD4 cell counts > 500/microl: What predominates? 2

2. CD4 cell counts from 200 – 500 /microL present w/ ? 2

3. CD4 cell counts less than 200/microL generally have? 2

1. CD4 cell counts > 500/microl—
-benign & malignant brain tumors and
-metastases predominate

2. CD4 cell counts from 200 – 500 /microL present w/
-HIV-associated cognitive and
-motor disorders—usually not focal lesions

3. CD4 cell counts less than 200/microL generally have
-opportunistic infections, and
-AIDS-associated tumors

14

What is the definition of Psychosis?

…disturbance in the perception of reality, evidenced by hallucinations, delusions, or thought disorganization. Psychotic states are periods of high risk for agitation, aggression, impulsivity and other forms of behavioral dysfunction.”

15

Psychosis Occurs in a Number of Disorders:
9

1. Schizophrenia
2. Bipolar mania
3. Major depression with psychotic features
4. Schizoaffective disorder
5. Alzheimer's disease
6. Delirium
7. Substance induced psychotic disorder
8. Delusional disorder
9. Psychosis secondary to a medical condition

16

Evaluation
1. Mental status exam? 2

2. Medical evaluation? 9

1.
-Mini-mental exam
-Observation of patient in general

2. '
-VS including pulse ox
-PE
-Chem panel
-CBC
-Thyroid functions
-UA
-Drug screen
-Additional testing as indicated

17

Adverse effects of Cocaine use? 5


Physical Sx due to sympathetic nervous system stimulation would be? 5

1. Anxiety/irritability
2. Panic attacks
3. Suspiciousness/paranoia
4. Grandiosity/impaired judgment
5. Psychotic Sx—delusions/hallucinations

1. Flushing/diaphoretic
2. Tachycardia
3. Pupil constriction
4. HTN
5. Hyperthermic

18

Cocaine Use
1. R/O what?
2. Arrange and decide on what kind of tx?
3. Withdrawl psychological features? 5
4. Physical symptoms? 4

1. R/O adverse medical effects and serious harmful psychological effects

2. Arrange for in- or out-patient drug treatment program

Withdrawal Symptoms:
3. Prominent psychological features:
-Depression, anxiety, fatigue
-Difficulty concentrating,
-craving cocaine
-Increased sleep,
-increased appetite

4. Physical Symptoms:
-Minor and rarely require treatment
-Arthralgia's,
-tremor,
-chills

19

Cocaine: Treatment of withdrawal? 4

What do we need to determine at discharge? 2

Treatment of withdrawal:
1. Mainly supportive
2. Allow patient to sleep and eat as needed
3. No meds shown to help
4. Hospitalization mainly for psychological symptoms

Determining discharge:
1. Psychosocial evaluation for treating the addiction
2. Usually treated as outpatient, so if cleared medically and by psych can be discharged

20

Methamphetamine

S & Sx of overdose/intoxication: (Its a sympathomimetic)‏? 5

1. Flushing/diaphoretic
2. Tachycardia
3. Pupil constriction
4. HTN
5. Hyperthermic

21

Methamphetamine
1. Associated with variety of psychiatric symptoms? 4

2. Dx? 2

1. Associated with variety of psychiatric symptoms:
-Paranoia, psychosis and delusions
-Homicidality and suicidality
-Mood disturbances
-Anxiety and hallucinations

2. Diagnosis:
-Sympathomimetic toxidrome
-Differentiating it from cocaine and PCP

22

Methamphetamine
Evaluation:
Complications? 4

Check what labs? 7

1. Complications:
-hypovolemia,
-metabolic acidosis
-hyperthermia and
-rhabdomyalysis

2. Check:
-Serum lytes
-Serum lactate
-Creatinine kinase (CK)‏
-Aminotraferases
-Clotting times
-Renal function
-ABG

23

Methamphetamine Treatment
3

What should we generally try to avoid? 3

What is contraindicated? 1

1. Control agitation w/ benzodiazepines or w/ second generation anti-psychotics
2. Control hyperthermia!!!/fluid resuscitation
3. Hypertension:
Treated w/ nitroprusside or phentolamine

1. Avoid beta-blockers
2. Use of activated charcoal is rarely indicated
3. Physical restraints UNDESIRABLE

1. Succinylcholine is CONTRAINDICATED

24

Methamphetamine Tx Pitfalls
5

1. Failure to respect agitation and potential for violence

2. Failure to treat hyperthermia

3. Failure to recognize rhabdomyalysis

4. Failure to consider associated illness and trauma

5. Failure to note risk of contamination of drug ingestion

25

Neuroleptic Malignant Syndrome (NMS)
1. What is it?
2. Most often seen with?
3. Symptoms? 4

1. Life threatening neurologic emergency associated with the use of neuroleptic agents:
2. Most often seen w/ the first generation high potency agents --Every class has been implicated including antiemetic drugs (metoclopramide, promethazine, & Compazine)‏

3. Symptoms:
-Mental status change
-Muscular rigidity
-Hyperthermia
-Autonomic instability

26

NMS
1. USually develops when?
2. What is a risk factor?
3. Can be seen in pts where what meds are withdrawn?

1. Usually develops within the first 2 weeks of therapy
-Can develop at any time

2. Higher doses are a risk factor

3. Can be seen in patients where anti-parkinsonian meds are withdrawn: neuroleptic malignant-like syndrome

27

NMS Differential Diagnosis? 4

Neurologic and Medical disorder? 6

NMS
1. Serotonin syndrome: N/V/D, hyperreflexia, myoclonus
2. Malignant hyperthermia
3. Malignant catatonia
4. Acute intoxication w/ cocaine and ecstasy (rigidity not common)‏

Neurologic and medical disorders:
1. Infections
2. Seizures
3. Acute spinal cord injury
4. Heat stroke
5. Thyrotoxicosis
6. Withdrawal states

28

NMS Dx:
Most of the tests rule out other conditions?
7

1. MRI or CT of the brain
2. Lumbar puncture
3. CBC
4. Chem panel
5. Electroencephalography (rule out?)
6. Tox screen
7. Creatinine kinase elevation (4 x upper limit of normal)*

29

NMS Treatment

1. Only positive diagnostic test is what?

2. Most important to tx?

3. Managment of other psychotropic agents?

4. If due to dopamine withdrawal—manage how?

1. elevated creatinine kinase (>1000 IU/L)

2. STOP causative agent

3. Other potential psychotropic agents should be stopped also

4. restart dopamine

30

NMS Treatment—Intense Aggressive & Supportive Care

Aimed at preventing the following? 12

1. Dehydration
2. Electrolyte imbalance
3. ARF associated w/ rhabdomyalysis
4. Cardiac arrhythmias and cardiac arrest
5. MI
6. Cardiomyopathy
7. Respiratory failure, aspiration pneumonia, PE
8. DVT
9. DIC
10. Seizures
11. Hepatic failure
12. Sepsis

31

Alcohol Withdrawal
1. Presentation? 5
2. Goals of tx? 3

1.
-Minor
-Withdrawal seizures
-Alcoholic hallucinosis
-Delilirium Tremens (DTs)
-Ethanol poisoning‏

2. Goals of treatment:
-Manage symptoms of withdrawal
-Prevent serious events
-Bridge patients to treatment for recovery

32

Withdrawal Seizures
1. Usually occurs when?
2. More common in which pts?
3. Patterned how?
4. Treat with? 2

1. Usually occur 12-48 hours after last drink

2. More common in patients w/ long history of chronic alcoholism

3. Usually singular or several over short period

4. Treat w/ benzodiazepines and if necessary phenobarbital

33

Alcoholic Hallucinosis
1. Develops when?
2. What kind?
3. What is usually absent? 2
4. Therapy?

1. Develop within 12-24 hours after last drink and resolve within 24-48 hours

2. Usually visual, but auditory and tactile can occur

3. NO clouding of the sensorium and VS normal

4. Supportive therapy

34

Delirium Tremens (DTs)‏
1. Begins when?
2. Mortality?
3. Symptoms and signs? 6

1. Begins between 48-95 hours after last drink and can last 1-5 days
2. Mortality rate of 5%

3. Symptoms and signs:
-Hallucinations
-Disorientation
-Agitation
-Tachycardia, HTN, fever
-Diaphoresis
-These all lead to problems w/ fluid and electrolyte status

35

DTs—assessment & management

Step 1? 1

Step 2? 4

Step 3? 1

Step 4? 2

1. Rule out alternative diagnoses

2. Control symptoms/supportive care:
-Benzodiazepines
-IV fluids
-Nutritional supplementation—K+, Magnesium
-Thiamine*

3. Close monitoring—sometimes ICU**

4. If high-dose benzodiazepines not working for DTs:
- Can add phenobarbital
- Do not give antipsychotics

36

Ethanol Intoxication (Acute)
1. Diagnosis of exclusion—presents with changes in mental status? 4

2. How do serum ethanol conc correlate with symptoms?

3. Therapy?

4. Dont give what?

1. Diagnosis of exclusion—presents with changes in mental status:
-Hypoglycemia
-Hypoxia
-Head trauma
-Poisoning by other agents

2. Serum ethanol concentrations do NOT correlate closely with symptoms

3. When the diagnosis is made treatment is supportive
-Remember IV thiamine! Prevents- wernicke or korsakoffs

4. Dont give antipsychotics because they lower the seizure threshold

37

What are panic attacks?

Must R/O what? 7

1. “…characterized by the sudden onset of intense fear and by the abrupt development of specific somatic, cognitive and affective symptoms”

2. Must rule out medical disorders:
-Angina
-Arrhythmias
-COPD/asthma
-Temporal lobe epilepsy
-PE
-Hyperthyroidism
-Pheochromocytoma

38

Panic attacks
Hx questions? 3

- Life stressors
- Pt concerns and fears
- Recurrent substance abuse

39

Depressive states
1. Symptoms? 7
2. Depends on what?
3. Always ask about what?
4. R/O?

1.
-Anhedonia
-early morning awaking
-lethargy
-changes in appetite
-decrease in libido
-poor hygiene
-poor concentration

2. Depends on severity

3. ALWAYS ask about suicidal, homicidal, and manic states

4. Rule out medical cause

40

Evaluation for suicide risk:
7

1. Presence of suicidal or homicidal ideation, intent or plan
2. Access to means for suicide and the lethality of those means
3. Presence of psychotic sx, command hallucinations, or severe anxiety
4. Presence of alcohol or other substance use
5. **History and seriousness of previous attempts
6. Family history of or recent exposure to suicide
7. Degree of hopelessness and impulsivity

41

Suicidal State—Assessing the Patient
Management? 3

1. Reducing immediate risk [may mean hospitalization]

2. Managing underlying factors

3. Monitoring and follow-up

42

Schizophrenic Disorders
1. Primarily presents with what?

2. Hx?

1. Primarily presents with psychosis and detiriation in functional capacity

2. History:
-homicidal/suicidal thoughts
3. Mental status exam
4. Ask about ? & ?
Medical history

43

Schizophrenic Disorders


May need the following tests if indicated? 4


May need (if indicated by hx or PE)‏
-MRI or CT of head
-Heavy metal screen
-EEG
-Tests for Hep C, HIV

44

Schizophrenic Disorders
Tx?

Psychosis alone does not meet the legal criteria for involuntary treatment

Treatment:
1. Injectable antipsychotics
-Some of the second generation antipsychotics come as orally disintegrating tablets for the cooperative patient

45

Paranoid States
1. May occur with what?
2. Depending on particular paranoia and illness in what ways may you manage?

3. Clear mediically for? 3

4. Consult with?

1. May occur w/ other psychiatric illnesses

2. Depending on particular paranoia and illness may be treatable with meds may or may not require involuntary hospitalization

3. Clear medically for delirium, other cognitive dysfunctional medical conditions

4. Consult with Psych

46

What is catatonia?

It is a behavioral syndrome inability to move normally DESPITE the physical capacity to do so

47

Catatonia
Signs and symptoms? 6

And more rarely seen? 2

Signs & Symptoms:
1. Immobility
2. Stupor
3. Mutism or incomprehensible phrases
4. Muscular rigidity w/ waxy flexibility
5. Posturing
6. staring

More rarely seen:
1. Negativism
2. Automatic obedience

48

Etiologies of catatonia?
9

1. Major depression
2. Manic episode
3. Epilepsy
4. Encephalitis
5. Meds: antipsychotics, benzodiazepine withdrawal

Misc.:
6. Hepatic encephalopathy
7. SLE
8. Wilson’s disease
9. Lyme disease

49

Catatonia--Differential
8

1. NMS
2. Serotonin syndrome
3. Malignant hyperthermia
4. Nonconvulsive status epilepticus
5. Parkinson disease
6. Stroke
7. Delirium
8. Dementia

50

Catatonia
Tx? 5

1. Treat underlying cause:
-Usually occurs in the context of a underlying psych disorder
2. May be precipitated by a general medical disorder**
3. Supportive
4. Lorazepam**
5. ECT: mortality may increase if not begun within 5 days of symptom onset

51

Manic State
1. S&S? 6



2. Management? 4

1. spending spree
2. no sleep
3. gambling
4. lots of high risk sex
5. risky behaviors
6. mood swings


Management:
-Discontinue antidepressants
-Evaluate and treat substance abuse
-Drugs used to induce remission
-ECT

52

Drugs that induce remission in a manic state? 4

1. Lithium carbonate
2. Anticonvulsants
3. Antipsychotics
4. Benzodiazepines

53

Labs to check before giving lithium carbonate?
5

Need to check:
1. BUN,
2. creatinine,
3. thyroid function
4. Pregnancy test for menstruating women
5. ECG for patients > the 40 yrs old

54

1. What is conversion disorder?

Neurologic symptoms that are inconsistent with a neurologic disease, but cause distress, and/or impairment

55

1. What is somatization?
2. Symptoms? 3
3. Etiology?
4. May be influenced by what?
5. Tx?

1. Syndrome of nonspecific physical symptoms that are distressing

2. Symptoms may be caused/exacerbated by:
-Anxiety
-Depression
-Interpersonal conflict
3. May be conscious or unconscious
4. May be influenced by a desire for the sick role or for personal gain**



5. Psych referral

56

Serotonin Syndrome
1. Severity?
2. What is it?
3. Occur in what time period? Resolve when?
4. Spectrum of symptoms usually include?

1. Potentially life-threatening**

2. Increased serotonergic activity in the CNS


3. Occurs over hours
Usually resolves within 24 hours


4. Spectrum of symptoms usually include:
-Mental status changes
-Autonomic hyperactivity
-Neuromuscular abnormalities—hyperreflexia**

57

Serotonin Syndrome—Diagnosis
Hunter Criteria:
Must be taking a serotonergic agent
And meet ONE of the following criteria:
5

1. Spontaneous clonus
2. Inducible clonus PLUS agitation or diaphoresis
3. Ocular clonus PLUS agitation or diaphoresis
4. Tremor PLUS hyperreflexia
5. Hypertonia PLUS temperature above 38ºC PLUS ocular clonus or inducible clonus

58

Serotonin Syndrome—Treatment
6

1. Discontinuation of serotonergic agent

2. Supportive care:

3. Sedation w/ benzodiazepines

4. Control of hyperthermia—eliminates excessive muscle activity

6. Administration of serotonin antagonists:

59

Serotonin Syndrome—Treatment
1. Supportive care includes? 3
2. Serotonin antagonists? 2

1. Oxygen
2. IV hydration
3. Continuous monitoring—normalizing VS


1. Cyproheptadine (Periactin)
2. Antihistamine with nonspecific serotonergic antagonist proerties

60

Involuntary Psychiatric Admissions

Criteria? 3

Legal standards specifying criteria for civil commitment vary widely from state to state

1. Presence of mental illness is a prerequisite

Other criteria frequently used are:
2. Dangerous behavior toward self or others
3. Inability to adequately care for self

61

What disorders does the term mentally ill include:

Some states specifically exclude certain disorders, such as? 4

Again it varies widely

The statutes do not include specific psychiatric diagnoses

They define mental illness in terms of its effect on the individual’s thinking or behavior

Most include some deleterious effect of the illness and many include aspects of dangerousness

1. alcoholism,
2. drug addiction and
3. epilepsy;
4. others include these disorders

62

Types of Involuntary Hospitalization

Emergency detention:
1. Can be initiated by who? 3
2. Generally brief: can range from? 2

Obervational commitment
1. Usually limited to what?
2. Many states require what?

Extended commitment
1. What do you need?

Emergency detention:
1. Can be initiated by:
-another adult,
-the police,
-a physician
2. Generally brief:
-ranges from 24 hours,
-1-3 days Limited paperwork

Observational commitment:
1. Usually limited to physicians/hospital personnel,
2. Many states require court approval

1. Extended commitment:
-Formal application/sometimes 2 physicians
-Involves a hearing

63

Emergency hold:
Patient must meet criteria**
Must be evaluated by approved psychiatric personnel*
This step is the first step in initiating the involuntary commitment process:**
6

1. Legal/civil process
2. Form is filled out by Psychiatrist (usually)
3. Form goes to County attorney's office**
4. County attorney than decides if a petition should be filed
5. Once petition filed there is a initial hearing [patient is appointed a public defender]
6. Than there is a final hearing set—if patient is determined to need commitment to a state facility must be done in 5 days

64

Benzodiazepines
Use in the ER when? 4

1. Treatment of alcohol or sedative withdrawal
2. Acute agitation
3. Acute mania or agitated psychosis
4. Control drug-induced hyperexcitable states (Meth, PCP)‏

65

Benzodiazepines—SE
10

1. Sedation
2. Lethargy
3. **Respiratory depression
4. Impaired psychomotor skills and judgment
5. Cognitive dysfunction
6. Delirium (especially in elderly)‏
7. Ataxia
8. Exacerbation of COPD, sleep apnea
9. Cardiovascular instability
10. Death

66

Benzodiazepines--Overdose
1. Acute intoxication or overdose? 4

2. Severe overdose or in combo w/ other CNS drugs? 2

1. Acute intoxication or overdose:
-Slurred speech
-Incoordination
-Unsteady gait
-Impaired attention or memory

2. Severe overdose or in combo w/ other CNS drugs:
-Leads to stupor
-Can lead to coma

67

Antipsychotic Medications
“Neuroleptic” refers to?

first generation antipsychotics:
Chlorpromazine
Haloperidol

68

first generation antipsychotics:
Chlorpromazine
Haloperidol
1. With long term use have high risk of what? 3

2. Can also increase?

3. Other symptoms? 3

1. parkinsonian EPS
-Rigidity
-Bradykinesia
-Tremor

2. Can increase prolactin—causing galactorrhea and amenorrhea

3.
-NMS
-Prolonged QT interval
-Sudden death

69

Second Generation Antipsychotics

1. Agents? 3
2. Approved for tx of? 3
3. Primary SE? 4

1. Agents:
-Risperidone (Risperdol)‏
-Olanzapine (Zyprexa)‏
-Quetiapine (Seroquel)‏

2. Approved for treatment of:
-Schizophrenia
-Acute bipolar mania
-Acute agitation

3. Primary SE:
-Sedation
-Hypotension
-NMS
-Sudden death