Download Psychiatric emergency

Psychiatric emergency
Dagmar Seifertová
Psychiatrické centrum Praha
3. lékařská fakulta UK
Causes of psychiatric emergency
Psychic disorder
Agitation
Aggression
Autoaggression - suicidality
Drug use
Intoxication
Withdrawal syndrome
Adverse event – treatment relation
Neuroleptic malignant syndrome
Serotonin syndrome
Acute dystonia
Agranulocytosis - clozapine
Agitation
Psychic disorders
Somatic illness
Psychological crisis
Procedure: choice of contact
quick differencial diagnosis
choice of acute treatment
Choice of contact
Critic situation – first impression
Be in contact
Dialog – brief and clear
Goal – to have basic information
Leave patient to speak
Aggressive behaviour
Warning sings
Provocation – help refusion
medication refusion
Risky – first days hospitalisation
involuntary admission
asistence of police
First warning – verbal aggression
History of aggressive behaviour
Aggression – non-specific symptom
Personal history of aggression
Starters of aggression
Impulsive behaviour
Gun licence and possession of gun
Sings of arousal and aggitation
Family history of aggression
Management of aggression I.
Stay calm and do not be cross
We can express our distress – usually
lower patients aggression
Leave patient to speak about what is
hapenning with him
Aggression escalation – ask for help
Management of aggression II.
Never return back to patient
Take off oculars and jewellery
Safe exit – open doors, emergency
bells
5 person on one aggitated patient
Injection use – explaining
Restriction – frequent control
Isolation – frequent control
Etiology of psychiatric agitation
60% patients – sometime aggressive
Acute stress
Schizophrenia
Manic episode - often women
Drug dependency
Personality disorder
Demencia and mental retardation
Other causes of agitation
Somatic illness – with fever
Organic disorder CNS – injury, tumor,
bleeding, ischemia, infection
Postoperative states
Hypoglykemia
Acute intoxication
Drug withdrawal
Treatment of acute anxiety
Basic sings – panic, agitation,
hyperventilation, sweting, tremor
Verbal calming – leave patient speak
Breathe with patient
Explain symptoms
Pharmacological treatment
Pharmacological treatment of
acute anxiety
Benzodiazepine – peroraly
Diazepame – 10 mg
Alprazolame 1 – 2 mg
Lorazepame 1 – 2 mg
Clonazepame 1 – 2 mg
Longterm treatment – SSRI
Fear from medical procedure
Speak about fear- anestesia, pain,
handicap,life threatening, death
Brief and concise explanation
Describe desirable and active attitude
Possible family help
Possible institution help
Treatment of acute agitation –
psychotic patient
Short goal – minutes to hours
Antipsychotics
Combination with benzodiazepines
Mechanical restrictions
Isolations
Frequent controls
Atypical antipsychotics
Risperidone -solution 2 mg + BZD (
max.8mg)
Ziprasidone – i.m. 10 – 20 mg do max.
daily 40 mg ( effect in 15 min)
Olanzapine i.m. 10 mg - ( effect in 15
min )
AE – risperidone EPS
AE – olanzapine – sedation and
hypotension
Haloperidole
Haloperidole – parenterally
Dose - 5 mg ( max. 10 mg )
Dosing in short intervals – ( 30 – 60 min)
Combination with BZD – lorazepame 2 -3 mg
clonazepame 1 – 2 mg
diazepame 10 – 20 mg
Prophylactic use of antiparkinsonics
– biperiden, benztropin
Summary
Agitation is severe complication
Danger for patient and suroundings
Empathic attitude from begining
Primary – verbal calming
Secondary – pharmacological therapy
Mechanical restriction
Suicidality – risk factors
Depression
Gender - male
Age : >45 , or <19
Suicidal attempt in history
Alcohol and drug abuse
No social support
Loneliness
Family violence
Somatic illness and pain
Suicidal plan
Psychotic disorder with thought desorganisation
Evaluation of suicidal plan
Decision is serious ?
Motivation ?
Patient is mentally ill ?
Real problems in life ?
Hospitalisation is necessary ?
Suicidal plan
Preparation – type of suicide
good by letter
Circumstance- be alone
After suicide – did not look for help
lasting death wish
sorry for no sucess
Neuroleptic malignant syndrome- NMS
Neurological signs– extrapyramidal : diffuse muscule rigidity,
symetrical tremor,okulogyric crisis, trismus, dysfagia,
opistotonus
Autonomic dysfunction: fever > 38 st, tachycardia, tachypnoa,
sudden changes of blood pressure, profuse sweating,
dehydration, incontinence
Consciuosness: sopor – coma - delirium
Laboratory : leukocytosis , creatinphosphocinase multiple
increase ( > 1,33 mkat ), myoglobinuria, diffuse EEG
abnormality
Risk factors
Higher dose of incisive AP and quick dose increasement
Higher number of i.m. aplication
Psychomotor agitation
Mechanical restriction
Dehydration – (humid and tropical climate, central heating)
Physical exhaustion
Concommitant somatic and infection disease
Preexisting subclinic CNS damage
Beginning of alcohol and drug withdrawal
Dopaminergic system dysfunction
Childern and teenagers
Hormonal dysbalance
Course and complications
Development : during 72 hours
Complications : myoglobinuric kidney failure
respiration disorders
cardiovaskular failure - arytmia
neuromuscular abnormalities
Mortality : 20 – 30 % ---- now decreased to 10 %
Incidence : 0,02 – 0,2 – 3,2 %
Differencial diagnosis
- Primary CNS disorder
- Lethal catatonia
- Somatic illness
- Malignant hyperthermia / anestézia
- Serotonin syndrome
- Heat stroke -
Hypothetical etiopatogenessis
Disturbance of dopaminergic neurotransmition
Dopamin blockade – nigrostriatal – EPS
hypotalamic – autonomic symptoms
reticular system – stupor
Dysbalance between dopaminergic and sertonergic system
Dysbalance GABA and acetylcholine
Dysfunction of second messenger in calcium regulation
Dysregulation of sympathic nervous systemu - hyperactivity
Polymorfism of dopaminergic and serotonergic receptors
Pharmacological variables
Causes of NMS ( from case reports)
incisive typical antipsychotics - haloperidole
depotní AP
combination : AP + antiparkinsonics (25 %)
AP + lithium
AP + antidepressants ( SSRI )
sudden withdrawl of antiparkinsonics
atypical antipsychotics
NMS treatment
1. Withdrawal : antipsychotics + lithiem + anticholinergics
2. Symptomatic therapy
dantrolene – muscule relaxant
1 mg – 10 mg / kg (50 mg i.v. 4 x daily)
bromocriptine - direct dopamine receptor agonist
7 – 60 mg daily
amantadine - nondirect dopamine receptor agonist
200 – 400 mg daily
levodopa dopamine precursore
2,5 – 5 g daily
lisuride dopamin receptor agonist
0,25 – 4 mg daily
elektroconvulzive therapy
BZD - lorazepame - 30 mg daily
Serotonin syndrome
Psychic symptoms:
confusion , aggitation,hypomania
Neuromuscular symptoms :
hyperreflexia,myoclonus,parestezia,
tremor,ataxia,movement discoordination,rigidity
Autonomic symptoms :
fever, swetting ,diarrhoea,tachycardia, flu like sings
Pharmacological risk
Dramatic increase of serotonergic transmition
1) Increase serotonine ( tryptofan) synthesis
2) Serotonine release to synaptic cleft
(amfetamins )
3) Blocade reuptake ( SSRI,SNRI,TCA)
4) Inhibition of metabolism ( IMAO, RIMA )
5) Stimulation of seroton receptors ( agonists)
6) Hypersenzitivity postsynaptic receptors( lithiem)
7) Decrease of dopaminergic activity
Risk factors
Alteration of serotonergic system –
decreased monoaminoxydasis activity
Chronic somatic illneses – hepatal, lungs,
cardiovascular,hypertension,hyperlipidemia
Alcohol and drug abuse
Combination : SSRI + IMAO, RIMA, SNRI,
moodstabilizers, TCA, APP, třezalka,
metamaphetamine, erytromycin, linezolid
Treatment of serotonin
syndrome
1. Withdrawal of serotonergic drugs
2. Symptomatic treatment
BZD – lorazepame i.v. 1 – 2 mg,or other
Propranolol – 1 – 3 mg
Cyproheptadine 4 mg po 4 hod
( antagonist 5- HT)
Acute dystonia- clinical sings
Acute treatment complication –
antipsychotics
Abnormal head and neck posture
Spasmus of masticatory muscules
Swallowing disturbance
Oculogyric crisis
Tongue hypertonia and protrusion
Abnormal extremities posture
Could be painfull
Acute dystonie - treatment
anticholinergic antiparkinsonics
Mild sings - per os
Severe sings -parenterally
Biperidene 2,5 – 5 mg
Benzatropine – 2 – 6 mg denně
Catatonic spectrum
Catatonic schizophrenia
Affective disorder – severe depression ( melancholy)
Psychogenic stupor
Neuroleptic malignant syndrome
Serotonin syndrome
Somatic and neurological disorder
Agranulocytosis - clozapine
Risk – first 18 weeks of treatment (
75%)
Blood account –
weekly – first 18 weeks
monthly – first year
quarterly – maintenance treatment
risky - virosis
Witdrawal syndrome and
intoxication
Alcohol – delirium tremens
Drugs – different according
pharmacology
Antipsychotics – EPS, flu like symptom
Antidepressants – serotonin syndrome,
flu like symptom
Benzodiazepines – grand mal