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Flashcards in Psychiatric Emergencies Deck (96):
1

Factors Associated with Violence

Male
History of violence
Drug or ETOH abuse

2

Signs of Impending Violence

Provocative behavior
Angry demeanor
Loud, aggressive speech
Tense posturing
Frequently changing body position
Aggressive acts

3

Management of Potentially Violent Patients

Remove patient from contact with other patients
Expedite evaluation

4

Verbal Techniques for Angry Patients

Address violence directly
Set limits
Do not be provocative
Be honest and straightforward
Calm and soothing tone of voice
Concise, simple language
Offer choices and optimism
Stand at least 1 arms length away
Identify feelings and desires
Take all threats seriously
Protect yourself

5

Indications for Physical Restraints

Imminent harm to others
Imminent harm to self
Significant disruption of important treatment or damage to environment
Continuation of effective, ongoing behavior treatment plan

6

Use of Physical Restraints

Follow protocol
5 person restraint team
1 must be female
Monitor closely: position changes, respirations, avoid aspiration
DOCUMENT

7

3 Classes of Medications for Chemical Restraints

Benzodiazepines
1st generation antipsychotics
2nd generation antipsychotics

8

What class of medication is preferred when sedating patients with an unknown cause of agitation?

Benzodiazepines

9

Benzodiazepines Used in Chemical Restraint

Lorazepam
Midazolam

10

SE of Benzodiazepines

Respiratory depression

11

1st Generation Antipsychotic Agents

Haloperidol
Droperidol

12

SE of First Generation Antipsychotics

QT prolongation
Potential for causing dysrhythmias

13

When should 1st generation antipsychotics be avoided?

Alcohol withdrawal
Benzodiazepine withdrawal
Other withdrawal symptoms
Anticholinergic toxicity
Patients with seizures
Pregnant/lactating females

14

Second Generation Antipsychotic Agents

Olanzapine (Zyprexa)
Rispiradone (Risperdal)
Ziprasidone (Geodon)

15

Benefits of 2nd Generation Antipsychotics

Less sedation
Fewer extrapyramidal SE

16

Downside of 2nd Generation Antipsychotics

Less experience

17

When should a 1st or 2nd generation antipsychotic be used in violent patients?

Agitated patients with a known psychiatric disorder

18

Legal Considerations for Restraining Patients

Coworker agree with assessment and treatment
Reasons for restraint clearly documented
Duty to Warn

19

Post-Restraint Medical Evaluation

Complete set of vitals
Mental status and neuro exams
Blood glucose
R/O acute medical condition

20

Presentation of AIDS Encephalopathy

Change in mental status
Abnormal neurologic exam

21

Most Common Etiologies of AIDS Encephalopathy

Toxoplasmosis encephalitis
Primary CNS lymphoma
Progressive multifocal leukoencephalopathy
HIV encephalopathy
CMV encephalopathy

22

CD4 Count 500+ with CNS Lesions

Benign and malignant brain tumors
Metastases

23

CD4 Count 200-500 with CNS Lesions

HIV associated cognitive and motor disorders
Usually not focal lesions

24

CD4 Count Less than 200 with CNS Lesions

Opportunistic infections
AIDS-associated tumors

25

Define Psychosis

Disturbance in the perception of reality, evidenced by hallucinations, delusions, or thought disorganization

26

What disorders does psychosis occur?

Schizophrenia
Bipolar mania
Major depression with psychotic features
Schizoaffective disorder
Alzheimer's disease
Delirium
Substance induced psychotic disorder
Delusional disorder
Psychosis secondary to a medical condition

27

Evaluation in Psychosis

Mini-mental
Observation of patient in general
Vitals
PE
Chem panel
CBC
Thyroid functions
UA
Drug screen

28

Adverse Effects of Cocaine Use

Anxiety
Irritability
Panic attacks
Suspiciousness
Paranoia
Grandiosity
Impaired judgement
Delusions
Hallucinations

29

Physical Symptoms of Cocaine Use

Tachycardia
HTN
Hyperthermic
Diaphoretic
Dilated pupils
Hyper-reflexia
Resting tremor

30

Withdrawal Symptoms of Cocaine

Depression
Anxiety
Fatigue
Difficulty concentrating
Craving cocaine
Increased sleep
Increased appetite
Arthralgias
Tremor
Chills

31

Treatment of Withdrawal of Cocaine

Supportive
Allow patient to sleep and eat as needed
Hospitalization for psychological symptoms

32

When can a patient who is high on cocaine be discharged?

Must be cleared medically and by psych

33

Signs and Symptoms of Methamphetamine Overdose

Tachycardia
HTN
Hyperthermic
Diaphoretic
Dilated pupils
Hyper-reflexia
Resting tremor
More mood disturbances

34

Psychiatric Symptoms with Methamphetamine Overdose

Paranoia
Psychosis
Delusions
Homicidality
Suicidality
Mood disturbances
Anxiety
Hallucinations

35

Diagnosing Methamphetamine Overdose

Sympathomimetic toxidrome
Differentiate from cocaine and PCP

36

Complications of Methamphetamine Overdose

Hypovolemia
Metabolic acidosis
Hyperthermia
Rhabdomyolysis

37

Labs to Draw in Methamphetamine Overdose

Electrolytes
Serum lactate
Creatinine kinase
Aminotransferases
Clotting times
Renal function
ABG

38

Treatment of Methamphetamine Overdose

Control agitation
Control hyperthermia
Fluid resuscitation
HTN: nitroprusside or phentolamine

39

What medication is contraindicated in methamphetamine overdose treatment?

Succinylcholine

40

Methamphetamine Treatment Pitfalls

Failure to respect agitation and potential for violence
Failure to treat hyperthermia
Failure to recognize rhabdomyolysis
Failure to consider associated illness and trauma
Failure to note risk of contamination of drug ingestion

41

Signs and Symptoms of Neuroleptic Malignant Syndrome

Mental status change
Muscular rigidity
Hyperthermia
BP lability
Tachycardia or bradycardia
Problems urinating
Unstable vitals

42

When does neuroleptic malignant syndrome (NMS) occur?

Usually: first 2 weeks of therapy
Any time
Anti-parkinsonian meds withdrawn

43

Diagnostics of Neuroleptic Malignant Syndrome (NMS)

Brain MRI/CT: R/O mass lesion
LP: R/O infection
CBC
Chem panel
Electroenphalography: R/O seizures
Toxicology screen
Creatinine kinase elevation: R/O rhabdomyolysis

44

Treatment of Neuroleptic Malignant Syndrome (NMS(

Stop causative agent
Potential psychotropic agents should be stopped
Restart dopamine if dopamine withdrawal

45

Treatment of Neuroleptic Malignant Syndrome (NMS) Preventing

Dehydration
Electrolyte imbalance
Acute renal failure
Cardiac arrhythmias or cardiac arrest
MI
Cardiomyopathy
Respiratory failure
Aspiration pneumonia
PE
DVT
DIC
Seizures
Hepatic failure
Sepsis

46

Steps of Alcohol Withdrawal

Minor
Withdrawal symptoms
Alcoholic hallucinosis
Delirium tremens (DT)
Ethanol poisoning

47

Goals of Treatment of Alcohol Withdrawal

Manage symptoms
Prevent serious events
Bridge patients to treatment for recovery

48

Withdrawal Seizures in Alcohol Withdrawal

12-48 hours after last drink
Common in long history chronic alcoholism
Singular or over short period

49

Treatment of Withdrawal Seizures

Benzodiazepines

50

Alcoholic Hallucinosis in Alcohol Withdrawal

Develop: 12-24 hours after last drink
Resolve: 24-48 hours
Usually visual
No clouding of sensorium
Vitals normal

51

Treatment of Alcoholic Hallucinosis

Supportive therapy

52

Delirium Tremens (DTs) in Alcohol Withdrawal

Begins: 48-95 hours after last drink
Resolve: 1-5 days
Mortality Rate: 5%

53

Signs and Symptoms of Delirium Tremens (DTs)

Hallucinations
Disorientation
Agitation
Tachycardia
HTN
Fever
Diaphoresis
Fluid/electrolyte issues

54

Assessment and Management of Delirium Tremens

R/O alternative diagnosis
Control symptoms: benzodiazepines, IV fluids, nutritional supplementation, thiamine*
Close monitoring

55

What medication can you use in delirium tremens (DTs) if benzodiazepines are not working?

Phenobarbital

56

Why can you not give antipsychotics in delirium tremens (DTs)

Lower the seizure threshold

57

Treatment of Acute Ethanol Intoxication

IV Thiamine

58

Define Panic Attacks

Sudden onset of intense fear and by the abrupt development of specific somatic, cognitive and affective symptoms

59

What medical disorders do you need to rule out before diagnosing panic attacks?

Angina
Arrhythmias
COPD/asthma
Temporal lobe epilepsy
PE
Hyperthyroidism
Pheochromocytoma

60

Symptoms of Depression

Lethargy
Anhedonia
Wake up early
Change in appetite
Decreased libido
Poor concentration
Suicidal thinking

61

What always needs to be asked about with depression?

Suicidal, homicidal, and manic states

62

Evaluating for Suicidal Risk

Presence of ideation, intent, or plan
Access to means and lethality of those means
Presence of psychotic symptoms, command hallucinations, or severe anxiety
Presence of alcohol or substance use
History and seriousness of previous attempts
Family history of recent exposure to suicide
Degree of hopelessness and impulsivity

63

Management of a Suicidal State

Reduce immediate risk
Manage underlying factors
Monitor and follow up

64

Presentation of Schizophrenic Disorders

Psychosis and deterioration in functional capacity

65

Examination of Schizophrenic Disorders

H&P
Homicidal/suicidal risk
Mental health exam
Ask about hallucinations and delusions

66

Diagnosis of Schizophrenic Disorders

CBC
CMP
MRI/CT of head
Heavy metal screen
EEG
Hep C
HIV

67

Treatment of Schizophrenic Disorders

Injectable antipsychotics
Orally disintegrating tablets for cooperative patients

68

What do patients with a paranoid state need to be cleared from for discharge?

Medically for delirium
Other cognitive dysfunctional medical conditions

69

Signs and Symptoms of Catatonia

Immobility
Stupor
Mutism or incomprehensible phrases
Muscular rigidity with waxy flexibility
Posturing
Staring
Negativism
Automatic obedience

70

Etiology of Catatonia

Major depression
Manic episode
Epilepsy
Encephalitis
Antipsychotics
Benzodiazepine withdrawal
Hepatic encephalopathy
SLE
Wilson's disease
Lyme disease

71

Treatment of Catatonia

Treat underlying cause
Supportive
Lorazepam
ECT

72

Signs and Symptoms of a Manic State

Risky behavior
Lots of energy
No/not much sleep
Gradiosity

73

Management of a Manic State

Discontinue antidepressants
Evaluate and treat substance abuse
Lithium carbonate
Anticonvulsants
Antipsychotics
Benzodiazepines
ECT

74

Define Conversion Disorder

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

75

Define Somatization

Syndrome of nonspecific symptoms that are distressing

76

What can symptoms of somatization be caused or exacerbated by?

Anxiety
Depression
Interpersonal conflict

77

Management of Somatization

Thorough H&P
Judicious testing
Possible malingering
NO OPIOIDS
Need psych referral

78

Symptoms of Serotonin Syndrome

Mental status change
Autonomic hyperactivity
Neuromuscular abnormalities (hyper-reflexia)

79

Hunter Criteria for Diagnosing Serotonin Syndrome

Taking a serotonergic agent PLUS one of the following:
Spontaneous clonus
Inducible clonus + agitation or diaphoresis
Ocular clonus + agitation ro diaphoresis
Tremor + hyper-reflexia
Hypertonia + temp above 38C + ocular clonus or inducible clonus

80

Treatment of Serotonin Syndrome

Discontinuation of serotonergic agent
Oxygen
IV hydration
Continuous monitoring
Sedation with benzodiazepines
Control hyperthermia
Administer of serotonin antagonists

81

Medications with Serotonergic Activity

Codeine
Fentanyl
Meperidine
Tramadol
Linezolid
SSRIs
SNRIs
TCAs
MAOIs
Bupropion
Trazodone
Dopamine agonists
Triptans
St. Johns wort
Panax ginseng
Tryptophan
Drugs of abuse
Buspirone
Dextromethorphan
Lithium

82

Criteria for Involuntary Psychiatric Admission

Presence of mental illness
Vary from state to state
+/- danger to self or others
Inability to adequately care for self

83

Types of Involuntary Hospitalization

Emergency detention
Observational commitment
Extended commitment

84

Duration of Emergency Detention

1-3 days

85

Who can initiate an observational commitment?

Physicians or hospital personnel
Sometimes court approval

86

How does an extended commitment occur?

Formal application
2 physicians
Requires a hearing

87

Proper Use of Restraints

Prevention of injury to self or others
Prevention of serious physical damage to unit or disruption of ER
Control of patient so an evaluation can be done

88

Define Duty to Warn

If patient divulges that he/she is going to harm a specific person, it is our duty to warn that person of the patient's intentions

89

When are benzodiazepines used in the ER?

Treatment of ETOH or sedative withdrawal
Acute agitation
Acute mania or agitate psychosis
Control drug-induced hyper excitable states

90

SE of Benzodiazepines

Sedation
Lethargy
Respiratory depression
Impaired psychomotor skills and judgement
Cognitive dysfunction
Delirium
Ataxia
Exacerbation of COPD, sleep apnea
Cardiovascular instability
Death

91

Acute Intoxication or Overdose of Benzodiazepines

Slurred speech
Incoordination
Unsteady gait
Impaired attention or memory

92

Severe Benzodiazepine Overdose or in Combination with Other CNS Drugs

Stupor
Coma

93

What does long term use of antipsychotics have a high risk of?

Parkinsonian EPS
Rigidity
Bradykinesia
Tremor

94

SE of 1st Generation Antipsychotic Medications

Galactorrhea
Amenorrhea
NMS
Prolonged QT interval
Sudden death

95

2nd Generation Antipsychotics Treat What Conditions

Schizophrenia
Acute bipolar mania
Acute agitation

96

Primary SE of 2nd Generation Antipsychotic Medications

Sedation
Hypotension
NMS
Sudden death