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Q.26 LIFE-THREATENING CONDITIONS IN PSYCHIATRY CLASSIFICATION, DIFFERENTIAL DIAGNOSIS & TREATMENT
Terms in this set (54)
Patients who are experiencing severe changes in mood, thoughts, or behavior, or severe, potentially life-threatening drug adverse effects.
What assessement should be done in patients when mood, thoughts, or behavior is highly unusual or disorganized?
assessment must first be made whether the patient is a:
1) threat to self
2) threat to others
Threat to self, what is it?
Include inability to care for self(self neglect) or suicidal behavior.
Self neglect. who?
Concern for psychotic, demented or substance abusing patients because their ability to obtain food, clothing and appropriate protection from the elements is impaired.
Schizophrenia, depression, bipolar, or anxiety
Threat to others?
-Those who are actively violent-> assaulting staff members, throwing and breaking things.
-Those who appear hostile(potentially violent)
-Those who EXPRESS intent to harm another person(spouse, neighbour, public figure)
-Important to identify caregivers who cannot safely and adequately take care of their dependants
-Often psychotic with diagnoses such as
Physical disorders that may cause acute delirium, chronic organic brain disorders(dementia) or intoxication with alcohol or other substances.
Predictor of future episodes?
Prior history of violence or aggression!!
Classification according to causes
3)Adverse effect of treatment
3)Acute anxiety(phobia, panic disorder)
4)Psychotic patient(delusions, hallucinations, loss of reality)
5)Suicidality(depressive episode, MDD)
1)Intoxication(acute, harmful use)
2)withdrawal state(cravings, severe side effects
-Delirium tremens(depressants: alcohol, BZD)
Adverse effects of treatment
1)Neuroleptic malignant syndrome
5)Stevens-Johnson syndrome(toxic epidermal necrosis-> epidermis separates from the dermis->mucus membranes also)->lamotrigine
Psychiatric emergency in psychiatric disorders-> 1)Agitation, 2)aggression, 3)autoaggression
Agitation: MOST common in organic brain disorders(dementia)
-Extreme restlessness, often seen in anxiety disorders and other mental disorders.
-aka Psychomotor agitation
Psychiatric agitation etiology asbdbd
1)Anxiety disorders->acute stress, PTSD
3)Bipolar disorder, Manic episode->often women
4)Dementia, delirium, mental retard
5)Borderline or antisocial personality disorders.
-Serotonin syndrome(antidep/stimulants combo)
-neuroleptic malignant syndrome
2)Organic CNS disorder(tumor)
1)Verbal calming, never turn back!!
2)Be in contact, brief and CLEAR dialogue, but emphatize!!
3)Allow patient to speak
Goal of managemnent
Convey basic information to the patient
-Atypical; risperidone, olanzapine
-Typical; haloperidol, chlorprom!
BZD; lorazepam, diazepam, alprazolam
Restriction + isolation
-Ask where the patient want the syringe....
Agression. Who? who at risk?
-First warning-> Verbal aggression
-Typically seen in psychosis and hyperactive delirium
-First days of involuntary / administration to the hospital
-History of impulsivity/aggression??!!
-Family history of aggression?
-Possessing a gun?
1)Stay calm, explain your own distress, dont get aggressive!
2)Remove glasses and jewlery
3)never turn back to patient
4)Keep door open, emergency bells
5)Explain injections and procedures while taking patient down
6) 5 people on 1 patient
7)Frequent checks if restrained->every 30-mins->mental changes, self harm, sign of thrombosis/emboli, asphyxia, NMS.
8)I.M benzo+neuroleptic( resp. benzo??)
9) Leave patient to speak about what is happening with him, and ask WHAT would HELP HIM/HER!
Agitation in acute anxiety
Panic attack; sudden unexpected onset of intense fear, peaking within minutes, characterized by depersonalization, derealization and autonomic arousal, followed by total exhaustion and fear of another attack
Panic disorder: unresponsive to anxiolytics, except for ALPRAZOLAM high DOSE.
Explain attack+ breathing techniques(stomach breathing)/plastic bag.
First psychotic episode-> BZD P.O
SSRI and CBT for long term!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Antipsych are ineffective per se
BZD are ineffective???
Agression in acute psychosis
Goal: Stabilize ASAP - within minutes to hours Antipsychotics:
▪ Risperidone (2mg) - EPS
▪ Olanzapine (10mg) - Sedation + Orthostatic hypotension o
Ziprasidone- IM 10-20mg. max 40 daily.
▪ Haloperidol (5-10mg) !!!!!! only D2! very good! in delirium and in old patient, P.O, IM
• Preferably in combination with benzodiazepines
o Clonazepam (BZD) and NOT antipsychotics as 1st line treatment.
Tiapride (neuroleptic/antipsychotic agent) is typical 1st choice in elderly with psychosis or alcohol withdrawal syndrome!do not cause orthostatic hypotension. Very selective for limbic system
o More selective than Haloperidol and Risperidone
-Somatic, not better, organic,
Agitation is severe complication.
-Dangerous for patient and surroundings.
-Emphatic from beginning
-Tertiary-> mechanical restriction
Autoaggression/suicidality, risk factors
-Prevention success: eduaction of GPs
Rational thinking disturbance
Social support lacking
If suicial plan is present->assess for
-Avoiding rescue(does not ask for help)
-Violent method(shooting, hanging, train)
-If already attempted->sorry for not being successful?
MMSE-> undetected psychiatric diagnosis is frequent->Depression, schizophrenia.
Hospitalization- if increased risk->dont leave the patient alone, remove dangerous objects
SSRI-for depression-> increased risk initially. Combine with BZD initially.
Psychiatric emergencies in alcohol and drug dependency
Acute intox vs withdrawal
Delirium tremens->life threatning->1-4% mortality
-10-72 hours after last drink
konfirmasjon med tre mødre, markus sier halllu! BP-stasjonen faller ned i bakken, jeg svetter og får blodtryyksfall
Symptomatic+supportive(ions, hydration, vitamins)
Sedation->BZD(tonic clonic +delirium) + clomethiazole
Nootropics? piracetam, pyritinol.
Cause of death
glutamate toxicity, seizures, exhaustion, MI, stroke, arrhytmias
Psychiatric emergency, adverse events in connection with psychopharmacotherapy
Neuoleptic malignant syndrome
Antipsychotics->haloperidol->dopamine blockade->glutamate excitoxicity. New drug or increased dose.
1)Rapid development <72hrs
2)Consciousness changes(stupor coma)
3) EPS rigidity
4)ANS dysf->tachy, rr, bp, diaphoresis
High and rapid dose
use of depot injection in addition to P.O
1)Primary CNS disorder
->heatstroke->dizziness, mental confusion, headaches, seizures, weakness->unconsciousness, organ failure, death
Stop all drugs
BZD for agitation
Supportive-> cooling!! fluid!! monitoring
Excessive serotonin due to combination of 2 or more pro-serotonin drugs!
-Blocked reuptake + decreased breakdown
1)Mental changes->confusion, aggression, hypomania
2)Neuromuscular->Rigidity, myoclonus, hyperreflexia
3)Autonomic->tachycardia, tachypnea, sweating, fever, diarrhea
BZD for agitation
Serotonin antagonist->Cyproheptadine.(1st gen antihistamine+antiserotonin)
-Decreased dopamine and increased acetylcholine->antipsychotics
-Involuntary contraction of muscles-> repetetive movements/abnormal posture
Symptoms acute dystonia
Spasms of head and neck/masticatory
Dysphagia, impaired swallowing due to contraction of laryngeal and pharyngeal muscles->aspiration
Anticholinergics->benztropin, biperiden, benzo.
Clozapine in normal doses...
Monitor blood count-> weekly first 18 weeks.
Monthly for a year.
Stevens Johnsons syndrome
Severe dermatologics disease, desquamation.
Tx: supportive, intravenous fluids, and nasogastric or parenteral feeding. (corticosteroids??)
Feel hoplessness?-> plans etc-> finish-> its very normal!!->have ways to help.
BEnzo in elderly
also anticholeniergic!! contraindicated. Cardiac, and cognitive-> may lead to delirium
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