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Psych Emergencies Flashcards

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1
Q

What are factors assoc w/ pt violence?

A
  • male
  • hx of violence
  • drug or alcohol abuse
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2
Q

Signs of impending violence?

A
  • provocative behaviro
  • angry demeanor
  • loud, aggressive speech
  • tense posturing
  • frequently changing body position
  • aggressive acts
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3
Q

Dxs assoc w/ violence? (FIND ME)

A
  • Fxnl: psych (schizophrenia, paranoid, cataonic, mania) miscommunication (fear of rejection, dependecy, illness)
  • Infectious: CNS, meningiits, encephalitis, sepsis
  • Neuro: head injury/hemorrhage, postictal states, vasculitis, neoplasm
  • Drug related: alcohol, amphetamines, PCP, LSD, steroids
  • Metabolic: lyte abnorm, hypothermia/hyperthermia/ anemia, vit def (B, folate), wernicke’s encephalopathy, hypoxia
  • Endocrine: hypoglycemia, thyroid storm, cushing’s disease
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4
Q

Management of a violent pt? (verbal techniques)?

A
  • remove pt from contact w/ provocative pts
  • expedite eval
  • verbal techniques: address violence directly, set limits, don’t be provocative, be honest and straightforward, calm and soothing tone of voice, simple language, offer choices and optimism, stand at least 1 arm’s length away, ID feelings and desires, take all threats, seriously, and protect yourself
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5
Q

Indications for physical restraints?

A
  • if verbal techniques are not working and escalation occurs - get help!
  • use of restraints can be humane and effective, can help w/ dx and tx, remove ASAP, usually when chemical restraint is achieved
  • indications:
    imminent harm to others, to self, sig disruption of impt tx or damage to enviro
  • continuation of effective, ongoing behavior tx plan
  • should have 5 person restraint team, if female pt - one member must be female
  • once pt is restrained needs to be monitored closely: position, resp, avoid aspiration
  • documentation is rqd
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6
Q

3 classes of meds use as chemical restraints?

A
  • benzos
  • 1st gen antipsychotics: haldol
  • 2nd gen: resperdol, seroquel
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7
Q

When are benzos preferred as the chemical restraint?

A
  • when sedating pts when agitated from unknown cause
  • lorazepam and midazolam (shorter half life): both PO, IM, IV
  • can cause resp depresssion: monitor closely!!
  • can be used w/ first gen antipsychotic
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8
Q

1st gen antipsychotics used as chemical restraint? When should you avoid these?

A
  • haloperidal (PO, IM)
  • droperidol (IM, IV) - BBW prolong QT
  • both cause QT prolong w/ potential causing dysrthymias (torsades)
  • avoid:
    cases of EToH withdrawal
    benzo withdrawal
    other w/drawals
    anticholinergic toxicity
    pts w/ seizures
    pregnant and lactating females
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9
Q

2nd gen antipsychotics used as chemic restraints?

A
  • olanzapine (zyprexa)
  • risperidone (risperdal)
  • ziprasidone (Geodon)
  • less sedation and fewer extrapyramidal side effects
  • less experience using them so benzos and 1st gen antipsychotics first choice
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10
Q

For severely violent pts reqring immediate sedation - what should be given?

A
  • 1st gen or /+ benzo
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11
Q

For pts w/ agitation from drug intoxication - what should be given?

A
  • benzo
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12
Q

For pts w/ undiff agitation what should be given?

A
  • benzos preferred but 1st gen AP can be used
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13
Q

For agitated pts w/ known psych disorder what should be given?

A
  • 1st or 2nd gen AP
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14
Q

What should be included in post-restraint medical eval?

A
  • complete set of VS including pulse ox
  • thorough mental status and neuro exams
  • rapid blood glucose determination
  • r/o acute medical condition (brain bleed for ex)
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15
Q

Presentation of AIDS encephalopathy? MC etiologies?

A
  • presentation: change in mental status, abnorm neuro exam
  • must determine degree of immunosuppression
  • MC etiologies:
    toxoplasmosis encephalitis
    primary CNS lymphoma
    progressive multifocal leukoencephalopathy, HIV encephalopathy, CMV encephalitis
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16
Q

What is psychosis?

A
  • disturbance in perception of reality, evidenced by hallucinations, delusions, or though disorganization. Psychotic states are periods of high risk for agitation, aggression, impulsivity and other forms of behavioral dysfxn
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17
Q

Psychosis occurs in what disorders?

A
  • schizophrenia
  • bipolar mania
  • major depression w/ psych features
  • schizoaffective disorder (depression or mania occurs and then psychosis occurs at sep time)
  • alzheimers
  • delirium
  • substance induced psychotic disorder
  • psychosis secondary to medical condition
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18
Q

Eval of pt presenting w/ psychosis?

A 
- MSE:
mini mental, observation of pt
- med eval:
VS (including pulse ox)
PE
chem panel
CBC
thyroid fxns
UA
drug screen
add testing as indicated
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19
Q

What are the adverse effects of cocaine use?

A
  • anxiety/irritability
  • panic attacks
  • suspiciousness/paranoia
  • grandiosity/impaired judgement
  • psychotic sxs: delusions/hallucinations
  • physical sx due to SNS stim:
    tachycardia, tachypnea, HTN, hyperthermic, diaphoretic, dilated pupils
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20
Q

Withdrawal sxs of cocaine?

A
  • prominent psych features: depression, anxiety, fatigue, difficulty concentrating, craving cocaine, increased sleep, increased appetite
  • physical sxs: minor and rarely reqr tx, arthralgias, tremor, chills
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21
Q

Tx of cocaine withdrawal?

A
  • mainly supportive
  • allow pt to sleep and eat as needed
  • no meds shown to help
  • hosp mainly for psych sxs
  • determining d/c: psych eval for tx addiction, usually tx as outpt, so if cleared medically and by psych can be d/c
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22
Q

S/S of overdose/intoxication of meth?

A
  • tremor
  • muscle twitch
  • tachypnea
  • tachycardia
  • hallucinations
  • aggressive behavior
  • sweating, convulsions
  • panic
  • agitated
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23
Q

Meth is assoc w/ why psych sxs? Dx?

A
  • paranoia, psychosis, and delusions
  • homicidality and suicidality
  • mood disturbances
  • anxiety and hallucinations
  • dx: sympathomimetic toxidrome, diff it from cocaine and PCP
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24
Q

Eval of meth intoxication? Labs?

A
  • complications: hypovolemia, metabolic acidosis, hyperthermia, and rhabdo
  • check:
    lytes
    lactaet
    CK
    aminotraferases
    clotting times
    renal fxn
    ABG s
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25
Tx of meth intoxication?
- control agitation w/ benzos or w/ 2nd Gen AP - physical restraints are undesirable - succinylcholine is CI - control hyperthermia, fluid resuscitation - HTN: tx w/ nitroprusside or phentolamine, avoid BBs - use of activaed charcoal is rarely indicated
26
Meth tx pitfalls?
- failure to respect agitation and potential for violence - failure to tx hyperthemia - failure to recognize rhabdo (release of CK) - failure to consider assoc illness and trauma - failure to note risk of contamination of drug ingestion
27
What is neuroleptic malignant syndrome (NMS)? Sxs?
- life threatening neuro emergency assoc w/ use of neuroleptic agents: most often seen w/ first gen high potency agents, q class has been implicated including antiemetic drugs (metoclopramide, promethazine, compazine) - sxs: mental status change muscular rigidity hyperthermia autonomic instability
28
When does NMS usually develop?
- w/in 1st 2 wks of therapy - can develop any time - higher doses are a RF - can be seen in pts where anti-parkinsonian meds are withdrawn: Neuroleptic malignant like syndrome
29
DDx for NMS?
- serotonin syndrome: N/V/D, hyperreflexia, myoclonus - malignant hyperthermia - malignant catatonia - acute intoxication w/ cocaine and ecstasy (rigidity not common) - neuro and medical disorders: infections seizures acute spinal cord injury heat stroke thyrotoxicosis withdrawal states
30
Dx NMS?
most of the tests r/o other conditions: - MRI or CT of brain - LP - CBC - chem panel - EEG: r/o seizures - tox screen - CK elevation (4x upper limit of normal)
31
Tx of NMS?
- only + dx test is elevated CK (over 1000 IU/L) - STOP the causative agent - other potential psychotropic agents also should be stopped - if do to dopamine withdrawal - restart it
32
Intense aggressive and supportive care for NMS tx is aimed at preventing?
- dehydration - lyte disturbance - ARF assoc w/ rhabdo - cardiac arrhythmias and arrest - MI - cardiomyopathy - resp failure, aspiration pneumonia, PE - DVT - DIC - seizures - hepatic failure - sepsis
33
Goals of alcohol withdrawal tx?
- manage sxs of withdrawal - prevent serious events - bridge pts to tx for recovery
34
When do alcohol withdrawal seizures take place?
- 12-48 hrs after last drink - more common in pts w/ long hx of chronic alcoholism - usually singular or several over short period - tx w/ benzos and if necessary phenobarbital
35
When does alcoholic hallucinosis occur?
- develop w/in 12-24 hrs after last drink and resolve w/in 24-48 hrs - usually visual but auditory and tactile can occur - no clouding of sensorium and VS normal - supportive therapy
36
When do delirium tremens occur?
- begins b/t 48-95 hrs after last drink and can last 1-5 days - mortality rate of 5% - s/s: hallucinations disorientation agitation tachycardia, HTN, fever diaphoresis these all lead to problems w/ fluid and lytes status
37
Assessment and management of DTs?
1. r/o alt dx (subdural hematoma, meningitis) 2. control sxs/ supportive care: benzos, IV fluids, nutritional supp: K+, magnesium, thiamine 3. close monitoring: sometimes ICU 4. if high dose benzos not working for DTs: can add phenobarbital, don't give antipsychotics b/c lowers seizure threshold
38
Presentation of acute ethanol intoxication?
``` - dx of exclusion: presents w/ changes in mental status: hypoglycemia hypoxia head trauma poisoning by other agents - serum ethanol conc don't correlate closely w/ sxs - when dx is made: tx is supportive - thiamine to prevent Wernickes! ```
39
What are panic attacks? what medical disorders need to be r/o?
- characterized by sudden onset of intense fear and by abrupt development of specific somatic, cognitive and affective sxs - R/O medical disorders: angina arrhythmias COPD/asthma temporal lobe epilepsy PE hyperthyroidism pheochromocytoma
40
Hx questions to ask pt presenting w/ panic attack?
- life stressors - pt concerns and fears - recent substance abuse - PE: full exam - dx testing: lytes, thyroid screen, chem panel
41
Sxs of depression? What do you always need to ask about?
- sxs: anhydonia, lethargy, early morning awakening, change in appetite, poor hygeine, decreased libido, poor concentration: for longer than 6 wks - always aks about suicidal, homicidal, and manic states - r/o medical cause
42
Evaluation for suicide risk?
- presence of suicidal or homicidal ideation, intent, or plan - access to means for suicide and lethality of those means - presence of psychotic sx, command hallucinations, or severe anxiety - presence of alcohol or other substance use - hx and seriousness of previous attempts - family hx of or recen exposure to suicide - degree of hopelessness and impulsivity - have to reduce immediate (hosp maybe), manage underlying factors, monitor and f/u
43
Schizophrenic disorders presents as?
- w/ psychosis and deterioration in fxnl capacity - MSE, ask about harming self or others - PE : ask about hallucinations, delusions, ideas of reference
44
Lab tests to order for schizophrenic disorders?
- CMP - tox screen - chem panel - may need: if indicated by hx or PE: MRI of CT of head heavy metal screen EEG tests for Hep C, HIV
45
Tx of schizophrenic disorders?
- agitated pt: safety - psychosis alone doesn't meet legal criteria for involuntary tx - tx: injectable antipsychotics, some of 2nd gen AP come as orally disintegrating tabs for coop pt
46
Paranoid state - tx?
- may occur w/ other psych illnesses - depending on particular paranoia and illness may be tx w/ meds may or may not rqr involuntary hosp. - clear medically for delirium, other cog dysfxnl medical conditions - consuly w/ psych
47
S/S of catatonia?
- immobility - stupor - mutism or incomprehnsible phrases - muscular rigidity w/ waxy flexibility - posturing - staring - more rarely: negativism automatic obedience (will mimic what you do) -it is a behavioral syndrome inability to move normally despite physical capacity to do so
48
Etiologies of catatonia?
- major depression - manic episode - epilepsy - encephalitis - meds: APs, benzos withdrawal - misc: hepatic encephalopathy, SLE, wilson's, lyme disease
49
DDx for catatonia?
- NMS - serotonin syndrome - malignant hyperthermia - nonconvulsive status epilepticus - parkinson disease - stroke - delirium - dementia
50
Tx of catatonia?
- tx underlying cause: usually occurs in context of underlying psych disordrer, may be precipitated by general medical disorder - supportive - lorazepam - ECT: mortality may increase if not begun w/in 5 days of sx onset
51
S/S of manic state? Management?
- no sleep, risky behavior: gambling, sex, spending money carelessly, feel good - on a high, productive - management: d/c antidepressants, eval and tx substance abuse, drugs used to induce remission: lithium carbonate: (need to check BUN, creatinine, thyroid fxn, preg test, EKG for pts over 40) anticonvulsants antipsychotics benzos - ECT
52
What is conversion disorder?
- neuro sxs that are inconsistent w/ neuro disease, but causes distress, and/or impairment - psych comorbidity is common - in ER: do full H and P: neuro and reassure pt, do CT scan if something abnormal or pt is freq ER pt, refer to psych
53
What is somatization?
- syndrome of nonspecific physical sxs that are distressing - may not be fully explained by known medical condition after appropriate investigation - sxs may be caused/exacerbated by: anxiety depression interpersonal conflict - may be conscious or unconscious - may be influenced by a desire for sick role or for personal gain - management: take thorough H and P! testing, look for possible malingering, never give narcotics! - try redirecting pt, refer to psych
54
What is serotonin syndrome?
- potentially life threatening - increased serotonergic activity in CNS - etiologies: occurs over hours, usually resolves w/in 24 hrs - spectrum of sxs: mental status changes, autonomic hyperactivity, neuromuscular abnorm: hyperreflexia
55
Dx of serotonin syndrome?
Hunter criteria: - must be taking serotonergic agent - and meet 1 of the following criteria: - spontaneous clonus - inducible clonus + agititation or diaphoresis - ocular clonus + agitation or diaphoresis - tremor plus hyperreflexia, - hypertonia + temp above 38C + ocular clonus or inducible clonus
56
Tx of serotonin syndrome?
- d/c of serotonergic agent - supportive care: O2 IV hydration cont monitoring: normalizing VS - sedation w/ benzos - control of hyperthermia: elim excessive muscle activity - admin of serotonin antagonists (only given if pt severely affected): cyproheptadine (periactin) antihistamine w/ nonspecific serotonergic antagonist properties
57
Meds that may contribute to serotonin syndrome?
- analgesics: codeine, fentanyl, tramadol - abx: linezolid - antidepressants: SSRIs, SNRIs, TCAs, MAOIs, bupropion - dopamine agonists: levodopa, amantadine - triptans: sumatriptan - herbal: st johns wort, ginseng - drugs of abuse: amphetamines, cocaine, ectasy, LSD - misc: lithium
58
What is prereq for involuntary psych admission?
- varies state to state - pt must have mental illness - other criteria freq used: dangerous behavior towards self or others inability to adequately care for self
59
What disorders does the term mentally ill include?
- varies - statutes don't include specific psych dxs - they define mental illness in terms of its effect on individual's thinking or behavior - most include some deleterious effect of illness and many include aspects of dangerousness - some states exclude certain disorders: alcoholism, drug addiction, epilepsy
60
Types of involuntary hospitalization?
- emergency detention: can be initiated by: another adult, police, physician, generally brief: from 24 hrs to 1-3 days - observational commitment: usually limited to physicians/hosp personnel, many states reqr court approval - extended commitment: formal application/sometimes 2 physicians, involves a hearing
61
When do you use Benzos in ER? SEs?
- tx of alcohol or sedative withdrawal - acute agitation - acute mania or agitated psychosis - control drug induced hyperexcitable states (Meth, PCP) SEs: - sedation - lethargy - ***resp depression - impaired psychomotor skills and judgement - cog dysfxn - delirium (esp in elderly) - use haldol - ataxia - exacerbation of COPD, sleep apnea - CV instability - death
62
Signs of OD of benzos?
- slurred speech - incoordination - unsteady gait - impaired attention or memory - severe overdose or in combo w/ other CNS drugs: leads to stupor can lead to coma
63
SEs of first gen APs?
- aka neuroleptics - chlorpromazine - haloperidol - w/ long term use - have high risk of parkinsonian EPS: rigidity bradykinesia tremor - can increase prolactin: causing galactorrhea and amenorrhea - other SEs: NMS prolong QT sudden death - used for sedation and control of psychosis in emergent situations (MI)
64
2nd gen APs used? Indications? Ses?
- Risperidone - olanzapine (zyprexa) - quetiapine (seroquel) - approved for tx of: schizophrenia acute bipolar mania acute agitation - primary SE: sedation hypotension NMS sudden death
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