Download Special Psychiatric Emergency Presentations

Special Psychiatric
Emergency Presentations
Nicholas Cascone, PA-C
Emergencies related to
psych medications
 Antipsychotics side effects
 Akathisia responds to β-blocker therapy such as
propranolol
 Dystonia (torticollis, oculogyric crises, etc.) respond to
anticholinergics (e.g. benztropine, diphenhydramine)
 Parkinsonism requires dose reduction and
anticholinergic therapy as above
 Neuroleptic malignant syndrome: emergency
presentation with rigidity, fever, tachycardia, BP
lability, and altered mental status – discontinue
antipsychotic and give dantrolene or bromocriptine,
hydration, supportive treatment in intensive care
setting
Emergencies related to
psych medications
 Benzodiazepines
 Used frequently in the ED for anxiolysis or sedation
 Anxiolytics: alprazolam (Xanax®), lorazepam (Ativan®),
clonazepam (Klonopin®)
 Longer-acting anxiolytics/mild sedatives: diazepam
(Valium®), chlordiazepoxide (Librium®)
 Sedative-hypnotics: temazepam (Restoril®), triazolam
(Halcion®), flurazepam (Dalmane®)
 Overdose is treated with flumazenil
 Paradoxical response requires discontinuation
Anorexia nervosa
 Dx by usual signs and symptoms
 BMI 16, < 85% of expected weight for height
 Unexplained primary amenorrhea
 Derangement of body image
 ED treatment:
 Volume repletion
 Correction of electrolytes
 Aggressive refeeding leads to hypertonic
dehydration, hypernatremia, pancreatitis
Anorexia nervosa
 Criteria for hospitalization:
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Weight loss of 30% or more in 3 months
Severe metabolic disturbance
Suicidality
Failure to maintain outpatient weight contract
Family crisis or denial
Severe bingeing and purging
Need to initiate therapy (psychotherapy,
family therapy, pharmacotherapy)
Panic attack
 Symptoms
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Palpitations/tachycardia
Chest pain/pressure
SOB/smothering
Diaphoresis
Tremor
Choking sensation/globus
Nausea/abdominal complaints
Dizziness/lightheadedness/syncope
Paresthesia
Chills/hot flashes
Fear of: going crazy, loss of control, dying, syncope
Derealization/depersonalization
Panic attack – medical differential
 Cardiovascular: angina, MI, MVP, PACs
 Pulmonary: angina, PE, hyperventilation
 Endocrine: hyperthyroid, hypoglycemia,
pheochromocytoma, Cushing’s
 Neurological: stroke/TIA, partial seizure,
migraine, Ménière’s
 Drugs/medications: caffeine, cocaine, thyroid
meds, SSRIs, cannabis, steroids, β-agonists,
triptans, nicotine, hallucinogens, anticholinergics
 Withdrawal syndromes: alcohol, barbiturates,
benzodiazepines, opiates
Panic attack – treatment
 In ED: benzodiazepines
 Referrals
 Psychotherapy – cognitive-behavioral
 Psychiatry
 SSRI
 Buspirone
 Short-term “bridging” benzodiazepines
Emergencies involving alcohol
 Trauma – assault, MVA, other injuries
 25% of assaults involve alcohol
 45% of fatal MVAs involve alcohol
 Head trauma often overlooked when
presenting with alcohol intoxication
 Obtain CT of head when:
 History of head injury
 No improvement in 3 hours
 Worsening of mental status while under observation
Emergencies involving alcohol
 Withdrawal
 Four steps of alcohol withdrawal
 6 – 8 hours since last drink: autonomic
hyperactivity – tachycardia, diaphoresis, tremor
 24 hours since last drink: tactile and visual
hallucinations
 24 – 48 hours since last drink: motor seizures
 3 – 5 days since last drink: delerium tremens –
altered mental status, convulsive seizures, 5 –
15% mortality
Emergencies involving alcohol
 Treatment of alcohol withdrawal
 Fluid resuscitation with D5NS or D5LR and thiamine
(100 mg/L)
 Patient placed in a quiet area with minimal stimulation
 Lorazepam 2 – 4 mg IV q 15-30 minutes until light
sedation is achieved
 MgSO4: 4 g IV in 1 – 2 hours
 For pts with seizures:
 CT indicated if head trauma, focal seizure, persistent postictal defect in consciousness
Emergencies involving alcohol
 Criteria for admission
 Medical complications such as CHF, infection
 More than 8 mg of lorazepam needed
 Referral for treatment of alcoholism
Tests for conversion disorder/
malingering
 Sensation
 Yes/no test: pt closes eyes and responds yes/no to
touch stimulus – “no” response favors conversion
 Bowlus & Currier test:
 pt extends crossed arms, thumbs down, palms touching,
interlocking fingers, arms then rotated towards chest
 False response to sensory stimulus difficult d/t distortion of
position
 “Strength” test: pt closes eyes and moves touched
finger to assess “strength”. True sensory loss would
not allow pt to determine which finger is being tested
Tests for conversion disorder/
malingering
 Pain
 Gray test of abdominal pain
 With psychological pain, pt closes eyes during palpation
 With organic pain, pt watches palpation so they can guard tender
 Motor
areas
 Drop test: “paralyzed” extremity dropped from above the face will
miss it
 Thigh adductor test: examiner places hands against inner thighs
of patient. Pt is told to adduct normal leg against resistance. In
pseudoparalysis, other leg will also adduct
 Hoover test: examiner cups both heels of patient. Pt is told to
elevate normal leg. In pseudoparalysis, other leg will push
downward. Pt is told to elevate weak leg. Absence of downward
pressure indicates noncompliance.
Tests for conversion disorder/
malingering
 Coma
 Corneal reflexes retained in awake patient
 Seizure
 Resistance to covering of mouth & nose indicates
pseudoseizure
 Palpation of abdominal muscles reveals lack of
contraction in pseudoseizure
 Blindness
 Opticokinesis: tape with alternating black and white
sections pulled laterally in front of patient’s open eyes
induces nystagmus in patient with intact vision