Special Psychiatric Emergency Presentations
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Transcript 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:
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
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