SPMM Notes

Question 1

Delerium Tremens - Definition and Onset

Answer 1

• Toxic confusional state due to severe alcohol withdrawal symptoms
• Symptoms peak 72-96 hours after last drink

Question 2

Delerium Tremens Symptoms

Answer 2

• Cognitive
  
  • Confusion
  • Clouding of consciousness
  • Agitation
  • Sleep disturbance
• Psychiatric
  
  • Vivid hallucinations in all modalities
  • Fleeting paranoid delusions
• Physical
  
  • Severe tremor
  • Fever
  • Sweating
  • Tachycardia
  • Hypertension

Question 3

Risk Factors for DT and seizures

Answer 3

• Severe dependence
• Past delerium tremens
• Older patients
• Physical illness

Question 4

Delerium Tremens Prognosis

Answer 4

• 10% mortality if untreated

Question 5

Delerium Tremens - Management

Answer 5

• Treat any underlying infection, dehydration
• Ensure adequate fluid and electrolyte balance, give nutrition
• Optimise environment - well lit quiet room with adequate lighting
• Nursing support - offer consistent nursing with reassurance, reorienttation and explanation
• Chlordiaxepoxide sliding scale reducing regimen
• IM benzodiazepines may be used judiciously for quick sedation and safety
• IV Pabrinex (Thiamine supplementation
• Avoid Haloperidol (phenothiazine antipsychotics) due to risk of inducing seizures
• Warn about risk of withdrawal seizures and Wernicke’s encephalopathy

Question 6

Effect of Lithium on the Heart

Answer 6

• Bradycardia
• Syncope
• Hypotension
• Sinus node dysfunction
• Flattening of T-waves
• Oedema
• Arrythmias

Question 7

Lithium and Amiodarone

Answer 7

• Cardiac rrisk - may increase risk of prolonged QT and Torsade de Pointes i.e. serious arrythmias
• Increased risk of sudden hypothyroidism

Question 8

Lithium Induced Hypothyroidism

Answer 8

• About 20% of middle-aged women taking lithium long term present with hypothyroidism
• Usually reversible
• Easily treated with thyroxine - advised if raised TSH and any affective symptoms
• Not a contraindication for continuing lithium per se

Question 9

Antidepressants in Cardiac Disease

Answer 9

• Sertraline best according to SADHEART
  
  • Mirtazapine also safe
• TCAs arrythmogenic due to Na/K channel blockade, also cause hypotension/hypertension
• Fluoxetine - hepatic enzyme inductor therefore could affect levels of cardiac drugs e.g. amiodarone
• Venlafaxine - may cause hypertension
• Citalopram/Fluvoxamine - some QTc effects, require ECG monitoring

Question 10

Treatment Resistant Depression - Algorithm

Answer 10

• By definition 2 different antidepressants tried for >6 weeks at adequate dose
• Augmentation options:
  
  • Lithium
  • Thyroxine
  • High dose venlafaxine
  • 5HTP
  • SSRI + Mirtazapine
• Psychological interventions?
  
  • CBT
  • Family therapy
  • Psychotherapy
• If still no response second opinion
• ECT if all other measures fail (with consent)

Question 11

Venlafaxine - Indications, Contraindications and Monitoring

Answer 11

• NICE - reserve for failing to respond to two trials of other antidepressants
• Before initiating - ECG, electrolytes and BP should be measured
• Contraindicated in patients with:
  
  • Heart disease (including ECG abnormalities like prolonged QTc)
  • Electrolyte imbalances
  • Hypertension
• Also inquire about:
  
  • FHx heart disease
  • Other medication that might interact
• Take into account higher burden of side effects therefore patients more likely to discontinue, also higher propensity for withdrawal syndrome
• Monitor BP +/- U+Es every 6 months
• If signs of heart disease taper off slowly over a period of weeks/months

Question 12

Pregnant Woman Using Heroin - Management

Answer 12

• Outpatient detoxification - best time is during second trimester
  
  • Lowest possible dose of methadone
• Random UDS and daily methadone pickup
• Treat comorbid psychiatric conditions like anxiety and depression
• Work with obstreticians throughout and paediatricians around delivery - risk of neonatal opioid withdrawal syndrome
• Opioid misuse not itself reason to involve SS but should do if concerns about welfare of child - may need child protection proceedure
  
  • Can also help with housing
• Methadone compatible with breastfeeding and can be continued at a low dose after delivery
• Consider couples/family therapy - useful if partner uses substances

Question 13

Neonatal Complications of Opioid Misuse in Pregnancy

Answer 13

• Increased risk of miscarriage or intrauterine death
• Baby more likely to be premature or low birth weight
• Neonatal opioid withdrawal symptoms
• Respiratory depression

Question 14

Anorexia Nervosa - Inpatient Treatment Criteria

Answer 14

• BMI <13.5
• Severe depression and suicidal risk
• Rapid weigh loss in patients with a dangerously low weight
• Electrolyte imbalances leading to ECG changes (low K<3 mmol/L)
• Crisis situation
• Failed outpatient care (non-compliance)
• Dehydration
• Refusal to eat and drink

Question 15

Anorexia Nervosa - Inpatient Treatment Goals

Answer 15

• Setting should be appropriate for skilled refeeding, physical monitoring plus psychosocial interventions
• Goals are:
  
  • Addressing physical and psychiatric complications
  • Development of a healthy meal plan and weight gain/restoration
  • Addressing underlying psychological conflicts such as low self-esteem and planning new coping strategies
  • Enhancing communication skills

Question 16

Anorexia Nervosa - Inpatient Treatment Medical Interventions

Answer 16

• Weight restoration and monitoring - aim for weight gain betweek 0.5-1kg a week over 8-12 weeks
  
  • Dietician guided - target weight, 2500-3000 calories today over 3-4 meals plus snacks
• Rehydration and correction of serum electrolytes
• Following wieght restoration patient should be offered outpatient psychological treatment and physical monitroing should continue for at least 12 months
• No medication for anorexia specifically - Fluoxetine, TCAs may be used for comorbid depression

Question 17

Anorexia Nervosa - Psychological Interventions