Flashcards in Psychiatric Emergencies Deck (69)
1. Presentation? 5
2. Goals of tx? 3
-Delilirium Tremens (DTs)
2. Goals of treatment:
-Manage symptoms of withdrawal
-Prevent serious events
-Bridge patients to treatment for recovery
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
1. Develops when?
2. What kind?
3. What is usually absent? 2
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
Delirium Tremens (DTs)
1. Begins when?
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:
-Tachycardia, HTN, fever
-These all lead to problems w/ fluid and electrolyte status
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:
-Nutritional supplementation—K+, Magnesium
3. Close monitoring—sometimes ICU**
4. If high-dose benzodiazepines not working for DTs:
- Can add phenobarbital
- Do not give antipsychotics
Ethanol Intoxication (Acute)
1. Diagnosis of exclusion—presents with changes in mental status? 4
2. How do serum ethanol conc correlate with symptoms?
4. Dont give what?
1. Diagnosis of exclusion—presents with changes in mental status:
-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
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:
-Temporal lobe epilepsy
Hx questions? 3
- Life stressors
- Pt concerns and fears
- Recurrent substance abuse
1. Symptoms? 7
2. Depends on what?
3. Always ask about what?
-early morning awaking
-changes in appetite
-decrease in libido
2. Depends on severity
3. ALWAYS ask about suicidal, homicidal, and manic states
4. Rule out medical cause
Evaluation for suicide risk:
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
Suicidal State—Assessing the Patient
1. Reducing immediate risk [may mean hospitalization]
2. Managing underlying factors
3. Monitoring and follow-up
1. Primarily presents with what?
1. Primarily presents with psychosis and detiriation in functional capacity
3. Mental status exam
4. Ask about ? & ?
May need the following tests if indicated? 4
May need (if indicated by hx or PE)
-MRI or CT of head
-Heavy metal screen
-Tests for Hep C, HIV
Psychosis alone does not meet the legal criteria for involuntary treatment
1. Injectable antipsychotics
-Some of the second generation antipsychotics come as orally disintegrating tablets for the cooperative patient
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
What is catatonia?
It is a behavioral syndrome inability to move normally DESPITE the physical capacity to do so
Signs and symptoms? 6
And more rarely seen? 2
Signs & Symptoms:
3. Mutism or incomprehensible phrases
4. Muscular rigidity w/ waxy flexibility
More rarely seen:
2. Automatic obedience
Etiologies of catatonia?
1. Major depression
2. Manic episode
5. Meds: antipsychotics, benzodiazepine withdrawal
6. Hepatic encephalopathy
8. Wilson’s disease
9. Lyme disease
2. Serotonin syndrome
3. Malignant hyperthermia
4. Nonconvulsive status epilepticus
5. Parkinson disease
1. Treat underlying cause:
-Usually occurs in the context of a underlying psych disorder
2. May be precipitated by a general medical disorder**
5. ECT: mortality may increase if not begun within 5 days of symptom onset
1. S&S? 6
2. Management? 4
1. spending spree
2. no sleep
4. lots of high risk sex
5. risky behaviors
6. mood swings
-Evaluate and treat substance abuse
-Drugs used to induce remission
Drugs that induce remission in a manic state? 4
1. Lithium carbonate
Labs to check before giving lithium carbonate?
Need to check:
3. thyroid function
4. Pregnancy test for menstruating women
5. ECG for patients > the 40 yrs old
1. What is conversion disorder?
Neurologic symptoms that are inconsistent with a neurologic disease, but cause distress, and/or impairment
1. What is somatization?
2. Symptoms? 3
4. May be influenced by what?
1. Syndrome of nonspecific physical symptoms that are distressing
2. Symptoms may be caused/exacerbated by:
3. May be conscious or unconscious
4. May be influenced by a desire for the sick role or for personal gain**
5. Psych referral
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
Must be taking a serotonergic agent
And meet ONE of the following criteria:
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
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:
1. Supportive care includes? 3
2. Serotonin antagonists? 2
2. IV hydration
3. Continuous monitoring—normalizing VS
1. Cyproheptadine (Periactin)
2. Antihistamine with nonspecific serotonergic antagonist proerties