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Flashcards in Psychiatry Clerkship_3 Deck (109):
1

the earliest symptoms of etoh withdrawal begin when ?

6-24h after patient's last drink and depend on the duration and quantity of etoh consumption

2

when do seizures occur in alcohol withdrawal?

generalized tonic clonic seizures usually occur between 6-48h after cessation of drinking, with a peak around 13-24h

3

what fraction of etoh withdrawal patients with seizures develop DTs?

03-Jan

4

what electrolyte imbalance can predispose to seizures in etoh withdrawal?

hypomagnesemia

5

seizures in alcohol withdrawal are treated with what?

benzos, NOT anticonvulsants

6

EtOH withdrawal symptoms usually begin in how long?

6-24h

7

EtOH withdrawal symptoms typically last how long?

2-7 days

8

what are the mild EtOH withdrawal symptoms?

irritability • tremor • insomnia

9

what are the moderate EtOH withdrawal symptoms?

diaphoresis • hypertension • tachycardia • fever • disorientation

10

what are the severe symptoms of EtOH withdrawal?

tonic-clonic seizures • DT's • hallucinations

11

delirium tremens carries what percent risk of mortality?

15-25%

12

what percent of patients hospitalized for EtOH withdrawal get DTs?

5%

13

what is the most serious form of EtOH withdrawal

DT's

14

when do DT's occur?

usually begins within 48-72h post last drink but may occur later (90% of cases within 7 days)

15

what predisposes to DT's?

physical illness

16

in addition to delirium, symptoms of DT's may include what?

hallucinations (MC visual) • gross tremor • autonomic instability • fluctuating levels of psychomotor activity

17

what is the treatment for delirium tremens?

- benzodiazepines (chlordiazepoxide, diazepam, lorazepam) should be given in sufficient doses to keep the patient calm and lightly sedated then tapered down slowly [or depakote/tegretol taper] • - antipsychotics and temporary restraints for severe agitation • - thiamine,folic acid, and a multivitamin to treat nutritional deficiencies • - correct lytes and fluids • - monitor CIWA scale • - watch level of consciousness and watch for trauma • - check for hepatic failure

18

how many positives constitutes a positive CAGE questionnaire?

2

19

at risk or heavy drinking for men is how many drinks?

>4/d or >14/wk

20

at risk or heavy drinking for women is how many drinks?

>3/d or >7/wk

21

what are the biochemical markers used to monitor drinking?

BAL • LFT's • GGT • CDT • MCV

22

AST:ALT ratio >2:1 and elevated CGT suggest what?

excessive alcohol use

23

what is the effect of alcohol on LFTs and MCV?

↑LFTs • ↑MCV

24

what are the medications for alcohol dependence?

1. disulfiram (antabuse) • 2. naltrexone (revia, IM-vivitrol) • 3. acamprosate (campral) • 4. topiramate (topamax)

25

MOA of disulfiram?

blocks aldehyde dehydrogenase in the liver

26

disulfiram is contraindicated in what?

severe cardiac disease, pregnancy, psychosis

27

disulfiram is best used in whom?

highly motivated patients, as medication adherence is an issue

28

what is the MOA of naltrexone?

opioid receptor blocker • - works by ↓ desire/craving and high associated with EtOH

29

greater benefit for naltrexone use is seen in whom?

patients with family history of alcoholism

30

what will happen if you give naltrexone to a patient with opioid dependence?

precipitates withdrawal

31

what is the MOA of acamprosate?

structurally similar to GABA, thought to inhibit the glutaminergic system

32

how should acamprosate be used?

should be started postdetoxification for relapse prevention in patients who have stopped drinking

33

what is the major advantage of acamprosate?

can be used in patients with liver disease

34

acamprosate is contraindicated in who?

severe renal disease

35

what is the MOA of topiramate?

anticonvulsant that potentiates GABA and inhibits glutamate receptors • - reduces cravings for alcohol

36

what are the long term psychiatric complications of alcohol intake?

wernicke's encephalopathy → korsakoff syndrome

37

wernicke's encephalopathy is caused by what?

caused by thiamine (B1) deficiency resulting from poor nutrition

38

what is the course and prognosis of wernicke's encephalopathy?

acute and can be reversed with thiamine therapy

39

what are the features of wernicke's encephalopathy?

ataxia • confusion • ocular abnormalities (nystagmus, gaze palsies)

40

what is the course of korsakoff syndrome?

reversible in only 20% of patients

41

what is the MOA of cocaine?

cocaine blocks dopamine reuptake from the synaptic cleft, causing a stimulant effect • - dopamine plays a role in behavioral reinforcement (reward system)

42

what are the general effects of cocaine intoxication?

euphoria, heightened self-esteem, ↑/↓ BP, tachy/bradycardia, nausea, dilated pupils, weight loss, psychomotor agitation or depression, chills, and sweating

43

what are the dangerous effects of cocaine intoxication?

respiratory depression, seizures, arrhythmias, paranoia, and hallucinations (especially tactile). since cocaine is an indirect sympathomimetic, intoxication mimics the fight or flight response

44

what are the deadly effects of cocaine intoxication?

cocaine's vasoconstrictive effect may result in MI or stroke

45

cocaine overdose can cause death secondary to what?

cardiac arrhythmia • MI • seizure • respiratory depression

46

what is the management for mild to moderate agitation and anxiety due to cocaine?

reassurance of the patient and benzodiazepines

47

what is the treatment for severe agitation or psychosis due to cocaine?

antipsychotics (haloperidol)

48

what is the symptomatic support for cocaine intoxication?

control hypertension • arrhythmias

49

what do you do for a cocaine intoxicated patient whose temp is >102F?

it is a medical emergency and should be treated aggressively with ice bath, cooling blanket, and other supportive measures

50

treatment for cocaine withdrawal includes what?

- there is no FDA approved pharmacotherapy for cocaine dependence • - off label meds are sometimes used (disulfiram, aripiprazole) • - psychological interventions (contingency management, group therapy) are efficacious and are mainstay treatment

51

is abrupt abstinence of cocaine life threatening?

no

52

with respect to cocaine use, what is postintoxication depression?

crash: • malaise, fatigue, hypersomnolence, depression, hunger, constricted pupils, vivid dreams, psychomotor agitation or retardation- occaisonal suicidality

53

with mild to moderate cocaine use, withdrawal symptoms resolve when?

within 18 hours

54

with heavy, chronic cocaine use, withdrawal symptoms last how long?

may last for weeks, but usually peak in several days

55

what is the management for cocaine withdrawal?

treatment is supportive, but severe psychotic symptoms may warrant hospitalization

56

what is the MOA of classic amphetamines?

block reuptake and facilitate release of dopamine and norepinephrine from nerve endings, causing a stimulant effect

57

what are some examples of classic amphetamines?

dextroamphetamine (dexedrine) • methylphenidate (ritalin) • methamphetamine (desoxyn, ice, speed, crystal meth, crank)

58

heavy use of amphetamines can cause what?

amphetamine psychosis, a psychotic state that may mimic schizophrenia

59

what are the symptoms of amphetamine abuse?

dialted pupils, ↑ libido, perspiration, respiratory depression, chest pain

60

chronic amphetamine use can lead to what?

acne and accelerated tooth decay (meth mouth)

61

amphetamines are used medically in the treatment of what?

narcolepsy • ADHD • depressive disorders

62

what is the MOA of substituted "designer" amphetamines?

release dopamine, norepinephrine, sertonin from nerve endings

63

what are some exampled of substituted amphetamines?

MDMA, MDEA

64

substituted amphetamine use is associated with which situations?

dance clubs and raves

65

what can you get if you take substituted amphetamines with SSRI's?

serotonin syndrome

66

what are some of the possible consequences of amphetamine use?

↑ tolerance • can also → seizures

67

amphetamine overdose can → what?

hyperthermia, dehydration, rhabdomyolysis → renal failure

68

amphetamine withdrawal can → ?

prolonged depression; occaisionally complications of their long half life can cause psychosis

69

what is the treatment for amphetamine intoxication?

rehydrate, correct electrolyte balance, and treat hyperthermia

70

Ketamine can produce which effects?

tachycardia, tachypnea, hallucinations, amnesia

71

what is the mnemonic for PCP intoxication symptoms?

RED DANES • Rage • Erythema • Dilated pupils • Delusions • Amnesia • Nystagmus • Excitation • Skin dryness

72

what is the MOA of PCP?

a dissociative, hallucinogenic that antagonizes NMDA glutamate receptors and activates dopaminergic neurons. can have stimulant or depressant effects depending on the dose

73

what is the clinical presentation of PCP intoxication?

agitation • depersonalization • hallucinations • synesthesia • impaired judgement • memory impairment • assaultiveness • nystagmus • ataxia • dysarthria • hypertension, • tachycardia • muscle rigidity • high tolerance to pain

74

overdose of PCP can cause what?

seizures, coma, death

75

what are the types of nystagmus seen in PCP intoxication?

rotary, horizontal, vertical

76

which type of nystagmus is pathognomonic for PCP intoxication?

rotary

77

what is the treatment for PCP intoxication?

- monitor vitals, lytes, minimize sensory stimulation • - use benzos (lorazepam) to treat agitation, anxiety, muscle spasms, seizures • - use antipsychotics (haldol) to control severe agitation or psychotic symptoms

78

which types of hallucinations are seen in both cocaine and PCP abuse?

tactile and visual

79

more than with other drugs, intoxication with what leads to violence?

PCP

80

what are the symptoms of PCP withdrawal?

no withdrawal syndrome, but flashbacks may occur

81

agents in the sedative-hypnotics category category include what?

BDZ's • barbiturates • zolpidem • zaleplon • GHB • meprobamate

82

MOA of BDZ's?

potentiate the effects of GABA by ↑ the frequency of chloride channel opening

83

MOA of barbiturates?

potentiate the effects of GABA by ↑ the duration of chloride channel opening

84

which are more dangerous, barbiturates or BDZ's?

at high doses, barbiturates act as direct GABA agonists and have a lower margin of safety than BDZ's

85

What is GHB?

a dose specific CNS depressant that produces memory loss, respiratory distress, and coma. it is commonly used as a date rape drug

86

of all the types of withdrawals, withdrawal from what has the highest mortality rate?

barbiturates

87

intoxication with sedatives produces what?

drowsiness • confusion • hypotension • slurred speech • incoordination • ataxia • mood lability • impaired judgement • nystagmus • respiratory depression • coma • death

88

symptoms of sedative-hypnotics intoxication are synergistic when?

when combined with EtOH or opioids/narcotics

89

long term sedative use may → ?

dependence and may cause depressive symptoms

90

what is flumazenil?

a very short acting BDZ antagonist used for treating BDZ overdose

91

why should flumazenil be used with caution?

when treating overdose, it may precipitate seizures

92

what is the treatment for sedative-hypnotic intoxication

- maintain airway, breathing, circulation. montior VS • - activated charcoal and gastric lavage to prevent further absorption if drug ingested in prior 4-6h • - supportive care- improve respiratory status, control hypotension

93

what is the treatment specific to barbiturate intoxication?

alkalinize urine with sodium bicarbonate to promote renal excretion

94

what is the treatment specific to BDZ intoxication?

flumazenil in overdose

95

what is the treatment of choice for opiate overdose?

naloxone

96

what is the treatment for sedative-hypnotic withdrawal?

BDZ taper • carbamazepine or depakote taper may be used for seizure prevention

97

what is the most common cause of death from street heroin usage?

infection secondary to needle sharing

98

what is the MOA of opioids?

stimulate opiate receptors (μ, κ, δ) which are normally stimulated by endogenous opiates and are involved in analgesia, sedation, dependence

99

examples of opioids include what?

heroin • oxycodone • codeine • DXM • morphine • methadone • meperidine

100

what are the most commonly abused opioids?

oxycontin • vicodin • percocet • NOT heroin

101

what behaviors should alert a physician to opioid misuse?

losing medication • doctor shopping • running out of meds early

102

opioid intoxication causes what?

drowsiness • nausea/vomting • constipation • slurred speech • constricted pupils • seizures • respiratory depression • may → coma or death in overdose

103

what is the exception to opioids producing miosis?

Demerol Dilates pupils

104

which opioid is known to cause serotonin syndrome?

meperidine and MAOI together

105

what is the treatment for opiate intoxication?

- ensure adequate airway, breathing, circulation • - in overdose, administration of naloxone or naltrexone will improve respiratory depression but may cause severe withdrawal in an opioid-dependent patient • - ventilatory support may be required

106

what is the classic triad of opioid overdose?

Rebels Admire Morphine • Respiratory depression • Altered mental status • Miosis

107

can eating poppy seed bagels or muffins result in a urine drug screen that is positive for opioids?

yes

108

is opiate withdrawal deadly?

no

109

abstinence in the opioid-dependent individual →?

unpleasant withdrawal syndrome characterized by dysphoria, insomnia, lacrimation, rhinorrhea, yawning, weakness, sweating, piloerection, N/V, fever, dilated pupils, abdominal cramps, arthralgia, myalgia, hypertension, tachycardia, craving