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Flashcards in Psychiatric Emergencies Deck (69)
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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