-
- 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.
