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Flashcards in Psychiatric Emergencies Deck (69)
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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