Psychiatric emergency

    1. Psychiatric emergency
  • 🌱epidemiology:

– sex = equal

– time = night hours

– marital status = single (more common)

– presentation:

*20% suicidal

*10% violent or agitation

– diagnosis = mood disorder, schizophrenia and alcohol abuse

– hospitalizations = needed in 40% of cases

 

 

🌱Psychiatric emergency presentation

1- agitation

2- suicidal & deliberate self herm

3- LOC

4- substance misuse & dependency

5- Refusal to take food

6- catatonic immobility (waxy flexibility, the most easy type of schizophrenia )

7- panic attack

8- somatoform disorder

9- factitious disorder

10 – Side effects of medications, particularly Antipsychotics

11- Any Psychiatric Disorder may present to emergency room!!!

 

 

 

 

🌱Agitation :

 

definition:-

— anxiety-> apprehension feeling caused by anticipation (expectation) of danger (internal or external danger)

 

— fear -> anxiety cause by consciously recognized and realistic dangerous

 

— tension -> increased and unpleasant motor and psychological activity

 

— agitation -> The subjective feeling of being upset, angry, disturbed, or unable to rest.

 

— aggression -> Destructive or punitive behavior directed toward people or objects.

 

— Violence -> aggressive behavior that transgresses social norms.

 

** E.g. – boxing is an aggression, but street fighting is violence.

 

management in emergency room:-

 

1- protect your self & never confront the patient

2- think about the possible cause of agitation

3- calm the patient verbally

4- offer help and agreement, offer food,…

5- medication

*oral -> if refuse -> parental

*benzodiapepime groups

*anti-psychotic (Haloperidol 5-10mgs, Olanzapine 5-10mgs)

6- follow chart (Check vital signs each 5 minutes for the first hour and then half hourly until the patient become ambulant.)

7- restraint

8- call senior or specialist on call.

 

 

 

 

🌱 Extra pyramidal Side Effects (EPS) in the emergence:

 

* EPS include the following:

 

1. Neuroleptic Malignant Syndrome (NMS)

 

2. Acute Dystonia

 

3. Akathesia

 

4. Parkinsonism

 

5. Tardive Dyskinesia

 

 

* EPS occur after intake of:-

1-Antipsychotics (more with typical agents)

2- Antiemetic like metoclopramide.

3- Agents used for vertigo like Prochlorperazine (Stemitel).

 

 

 

1️⃣Neuroleptic malignant syndrome :

 

∆ Medical emergency, idiosyncratic reaction, may occurs even after single small sized dose

 

– more common in young male

– more common in early course of treatment

– may occur due to rapid increase in the doses of Antipsychotics.

 

∆ Rate: 0.02-2.4% of those who receive anti dopamines.

 

∆Mortality: 10-20%.

 

 

∆clinical features:

– elevated the temperature

– excessive sweating

– impaired the consciousness

– body rigidity

– autonomic disturbance (increased or decreased heart rate, or blood pressure.)

 

 

∆ Cause of death (complications)

– hypovolemic shock (due to excessive sweating) —> acute renal failure

– Myoglubinurea (due to muscle damage resulted from extreme rigidity —> renal failure

– Electrolyte disturbances.

– Aspiration (extreme muscle contractions and difficulty in swallowing)

– Respiratory failure.

 

 

∆  Investigations :

– increase WBCs

– elevated creatinine phosphokinase

 

 

∆  DDx

– Meningitis & Encephalitis

– Catatonic Schizophrenia.

 

 

∆  treatment

– stop the medication

– admission to ICU

– Check vital signs half an hourly + regular follow up.

– IV fluid

– Correct electrolyte disturbances (Na, K, Ca).

– Packing (to reduce the temperature)

– medication

* Benzodiazepine

* Bromocriptine (dopamine agonist) may be beneficial, start with small doses and increase gradually to maximum of 60 mgs /day.

* Dantroline (muscle relaxant) can be used up to 10 mgs/day, but in intensive care unit.

– call senior or specialist on call.

 

2️⃣ Acute dystonia

 

✓Definition

uncontrolled spasm and posturing of a group of muscles

 

– more common in male

– more common in early treatment (90% of case occur within first 5 days of starting medications)

– more with typical Antipsychotics, especially with Haloperidol, and Trifluperazine.

 

✓Clinical type

– Oculogyric crisis

*movement of the eye about the anteroposterior axis.

* Seen in children

– Blepharospasm

– Torticollis

– Opisthotonus

– Pleurothotonus

*tetanic bending of the body to one side.

 

✓Treatment

– Consider reduction in the dosage or changing the Antipsychotic.

 

– Anticholinergics

*Benztropine 1-4mg/day,

*Procyclidine 5-15mgs/day,

*Benzexhol 515mgs.day)

or

– Antihistamine

* Diphenihydramine (allermin) (25-200mgs/day)

 

**diazepam may use

 

 

3️⃣Akathisia

 

✓Definition

subjective feeling of restlessness

 

✓Treatment

– beta blocker like propanol

Or

– diazepam

**no benefit from anticholinergic

 

 

 

4️⃣Parkinsonism

 

 

5️⃣Tardive dyskinesia

 

✓Definition

bucco-lingular movement = chewing movement = rabbit syndrome

 

** may also be choreoathetoid movements of the extremities

 

– female more than male

– elderly more than young

 

— caused by long-term use of antipsychotic drugs

* incidence is related to drug dosage and duration of treatment

 

 

✓Treatment

– stop medication

– change to other antipsychotic like clozapine

 

** In some patients symptoms disappear within a few months after the drugs are withdrawn; in others symptoms may persist indefinitely.

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