1

PSYCHIATRIC EMERGENCIES

Psychiatry 2 – Practical # 4

Author: MUDr. Peter Janík, PhD.Supervisor: doc. MUDr. Ján Pečeňák, CSc.

Psychiatrická klinika LFUK a UNB, Bratislava

Podporené grantom KEGA č. 099UK-4/2012

DELIRIUM

2KEGA 099UK-4/2012

3

Delirium

severe global impairment of consciousness global cognitive impairment associated with behavioral abnormalities

stereotype response of brain to a variety of insults similar clinical features whatever the primary cause

rapid onset fluctuating course clinical features can vary markedly in severity at different time of the

day (typically worsening at night)

common in patients after major surgery or trauma 10-20 %

KEGA 099UK-4/2012

4

Delirium – clinical features

impaired clarity of consciousness reduced ability to direct, sustain and shift attention global impairment of cognition with disorientation,

impaired recent memory and abstract thinking nocturnal worsening of symptoms psychomotor agitation / inhibition emotional lability illusions / hallucinations (usually visual) incoherent speech paranoid delusions

KEGA 099UK-4/2012

5

Delirium – causes

Intracranial: head injury, intracerebral bleeding, encephalitis, meningitis, brain ischemia, raised intracranial pressure, tumor, dementia

Metabolic: electrolyte disturbance, hyperamonemia, uremia, anemia, cardiac failure, hypothermia, dehydratation

Endocrine: hypoglycemia, thyroid, parathyroid, pituitary, adrenal diseases

Infective: urinary tract infection, pneumonia, HIV, pancreatitis, febrile states, septicemia

Substance intoxication or withdrawal: alcohol, psychoactive substances, BZD, anticonvulsants, steroids, anticholinergic agents

Hypoxia: secondary to any cause

Trauma: head, chest, abdomen, polytrauma, burns

KEGA 099UK-4/2012

6

Delirium – causes

I I

WWAATTCCHH

DDEEAATTHH

←←

←←←←←←←←←←

←←←←←←←←←←

IInfectionnfection

WWithdrawalithdrawalAAcute metaboliccute metabolicTTraumaraumaCCNS pathologyNS pathologyHHypoxiaypoxia

DDeficiencieseficienciesEEndocrinopathiesndocrinopathiesAAcute vascularcute vascularTToxins or drugsoxins or drugsHHeavy metals eavy metals

KEGA 099UK-4/2012

7

Delirium – management

Treatment: identification and treatment of primary cause antipsychotics – pacification benzodiazepines (alcohol, PA substances, BZD withdrawal) supplementation of electrolytes, vitamins, rehydratation explanation, reorientation, reasurance

Prognosis: usually lasts less than 1 week amnesia for the period of delirium development of dementia death – 1 year mortality 50 %

KEGA 099UK-4/2012

AGITATION & AGGRESSION

KEGA 099UK-4/2012 8

Agitation / Agression

Agitation Severe anxiety associated with motor restlessness Seen in dementia, depression, anxiety disorders, withdrawal state Treatment: Benzodiazepines

Aggression Forceful, goal-directed action that can be verbal or physical; the

motor counterpart of the affect of rage, anger, or hostility. Seen in neurological deficit, temporal lobe disorder, impulse-control

disorders, mania, schizophrenia, personality disorders, intoxications Treatment: Antipsychotics, Benzodiazepines, use of restraints

9KEGA 099UK-4/2012

SUICIDALITY

KEGA 099UK-4/2012 10

11

Suicidality

one of the most common psychiatric emergency problems with mental disorder without mental disorder

suicidal ideation: thoughts about ending one's own life suicidal plan: planning of taking one's own life suicidal behavior: act of taking one's own life

KEGA 099UK-4/2012

12

Suicidality – psychiatrist's role

evaluation of actual state risk of suicidal behavior underlying mental disorder history of suicidal attempts presence of psychoactive substances social background

hospitalization or different intervention?

KEGA 099UK-4/2012

13

Suicidality – questions

How do you feel about the future?Have you ever thought that life was not worth living?Have you ever wished you could go to bed and not to wake up in the morning?Have you had thoughts of ending your life?Have you thought about how would you do it?Have you made any preparations?Have you tried to take your own life in the past?

KEGA 099UK-4/2012

14

Suicidality – risk factors

male gender age > 45 years unmarried suicidal attempt in history signs of chronic automutilation bad health condition actual or risk of loss in family / job insufficient social background suicidal plan

after the attempt: persistent wishes to be dead deadliness of chosen method elimination of lifesaving chance regret of lifesaving

KEGA 099UK-4/2012

15

Suicidality – underlying diagnoses

acute stress disorder anxiety disorder affective disorder

unipolar depression bipolar depression

schizophrenia schizoaffective disorder intoxication, withdrawal (psychoactive substances) personality disorders (borderline)

KEGA 099UK-4/2012

16

Suicidality – management

treatment of basic mental disorder (if present) psychotherapy (crisis intervention) psychosocial intervention psychopharmacotherapy

benzodiazepines antipsychotics

KEGA 099UK-4/2012

CATATONIA

KEGA 099UK-4/2012 17

18

Catatonia – causes

Psychiatric: schizophrenia, mood disorders – severe mania or depression,

neuroleptic malignant syndrome

Delirium: metabolic, endocrine, infectious, autoimmune disorders, drug-

related

Neurologic: Parkinsonism, postencephalitic states, seizure disorder, lesions of

thalamus, parietal and frontal lobe

KEGA 099UK-4/2012

19

Catatonia – symptoms & signs

increased resting muscle tone which is not present on active or passive movement

motor symptom of schizophrenia

Typical signs: mutism posturing negativism staring rigidity echopraxia/echolalia vaxy flexibility

KEGA 099UK-4/2012

Catatonia – clinical picture

Cruschmann, 1894

21

Catatonia – management

symptomatic treatment benzodiazepines electroconvulsive therapy

KEGA 099UK-4/2012

SEROTONINE SYNDROME

KEGA 099UK-4/2012 22

23KEGA 099UK-4/2012

Serotonine syndrome (SS)

rare, but potentially fatal syndrome occurs in the context of initiation or dose increase of serotonergic

agents result of overdose or drug combinations (MAOI, lithium) rapid onset, if treated usually resolved in 24-36 hours

Pathophysiology: ↑ production of serotonin due to ↑ availability of precursors ↓ metabolism of serotonin ↑ release of stored serotonin reuptake inhibition direct stimulation of serotonin receptors

24KEGA 099UK-4/2012

SS – symptoms & signs

confusion agitation hypersalivation, sweating myoclonus, rigidity, tremor, hyperreflexia, ataxia hyperthermia nausea, diarrhea mydriasis tachycardia hyper/hypotension

SS – clinical picture

Boyer & Shannon, 2005

26KEGA 099UK-4/2012

SS – management

if overdose – gastric lavage, activated charcoal rehydratation, cooled i.v. infusions antipyretics sodium bicarbonate – to prevent renal failure benzodiazepines – agitation, seizures, rigidity beta-blockers – to prevent dysrhytmia

NEUROLEPTIC MALIGNANTSYNDROME

KEGA 099UK-4/2012 27

28KEGA 099UK-4/2012

Neuroleptic malignant syndrome (NMS)

rare life-threatening idiosyncratic reaction to antipsychotic medication (usually typical AP) – incidence 0,07-0,2 %

mostly in first 4 weeks of treatment

D2 receptors blockade or ↓Dopamine availability in striatum (rigidity), hypothalamus (thermoregulation) → impaired Ca2+ →mobilization in muscle cells → rigidity

mortality: 5-20% respiratory failure renal failure cardiovascular collapse arrhythmias DIC

29KEGA 099UK-4/2012

NMS – symptoms & signs

hyperthermia > 38°C muscular rigidity agitation altered level of consciousness tachycardia, tachypnoe tremor hypo/hypertension ↑CK / urinary myoglobin, leukocytosis, metabolic acidosis incontinence/retention/obstruction

30KEGA 099UK-4/2012

NMS – management

ECT Dantrolen 1-2 mg/kg Amantadin, Bromocryptin

stop of taking antipsychotics benzodiazepines

rehydratation antipyretics sodium bicarbonate

31

Any questions?