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Emergencies in Psychiatry

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Richard Duffy

on 18 January 2013

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Transcript of Emergencies in Psychiatry

Serotonin Syndrome Emergencies in Psychiatry Dr Richard Duffy MRCPsych
Special lecturer in Psychiatry De-escalation
Quiet environment (single room)
Consistent staffing
If this does not work consider rapid tranquillisation (depending on Dx) Usually <24h
Related delirium may last for a few days
May be complicated by rhabdomyolysis
2002 Toxic Exposure Surveillance System
26,733 exposed; 7349 toxic; 93 deaths Supportive, IV access
Transfer to ED if severe
BZD for agitation and myoclonus (may be given IV)
Serotonin antagonists – cyproheptadine, methysergide
Symptomatic rx depending on symptoms Psychiatric
Confusion, hypomania, hallucinations, agitation, headache, coma
Tachycardia, diaphoresis, rigors, dilated pupils, hyperthermia, hypertension, nausea, diarrhoea
Hyperreflexia, myoclonus, tremor A rare but potentially fatal SE of any serotonergic agent
Caused by an increase in the quantity and activity of serotonin Small doses, titrate slowly - close monitoring
Consider anti-psychotic structurally unrelated, or with low DA affinity e.g. quetiapine, clozapine
Consider prophylaxis (bromocriptine)
Avoid depots & high potency anti-psychotics TRANSFER TO MEDICAL UNIT
Withdraw antipsychotics
Monitor BP, HR, T°C
Dantrolene & Bromocriptine
Sedation with BZD
Artificial ventilation may be required Fever
Muscular rigidity
Fluctuating consciousness
Labile BP
Elevated CK
Elevated WCC
Abn LFTs Can happen with any anti-psychotic, at any dose, at any time
Rapid titration
IM or IV administration
High potency typicals (e.g. Haloperidol, Fluclopenthixol)
Psychomotor agitation
Psychosis, alcoholism, Parkinson’s, hyperthyroidism, organic brain disease Seek anaesthetic advice
Amylobarbital 250mg IM
Paraldehyde 5-10ml IM
Will need to be in ICU
Consider IV treatment
Diazepam 10mg over at least 5 min
Repeat after 5-10 minutes up to x3
Haloperidol 10mg If fails after three rounds consider IM or sooner if patient or others at significant risk
Repeat every 45-60 min Reduce suffering for the patient

Reduce risk of harm to others by maintaining a safe environment Management Clinical Neuroleptic Malignant Syndrome Prognosis All anti-depressants (not just SSRIs)
Opoids (pethidine, tramadol, fentanyl, oxycodone)
CNS stimulants incl. cocaine, methylphenidate
5-HT1 agonists e.g. tryptans
Psychedelics – LSD, MDMA
Herbs incl. St Johns Wort, ginseng
Tryptophan, linezolid, lithium, valproate, L-dopa, ondansetron, olanzapine, risperidone Causes Rare at therapeutic doses
Often occurs after OD SSRI cause 71% Differential diagnosis NMS
Malignant hyperthermia
Substance abuse/withdrawal/ overdose Investigations FBC
Tox screne
ECG Signs Rhabdomyolysis Maintain high urine output
Sodium Bicarbonate for alklinization (target urine pH 6)
If necessary reduce tempature Severe Behavioral Disturbance Covers presentations from shouting to, attempting harm to self or others
Get all available information
Seek senior assistance early Causes Delirium
Acute psychiatric disorder
Challenging behavior in LD or brain injury
Unrelated to psychiatric disorder Management General Approach Get all available information
Look for evidence of psychiatric disorder
Establish potential triggers
Ensure your own safely and the safety of others Talking with patients Attempt to put them at ease
Explain what you are going to do
Ask clear questions
Be aware of your non-verbal communication
Listen actively
Clarify and summarize
Show empathy
Be neutral
Use open questions
Try and have the patient suggest a solution Non pharmacological Rapid Tranquill-isation Why Oral medications IM Medication Haloperidol 5mg
Olanzapine 5-10 mg
Zuclopenthixol 50-150mg
(repeat every 2/3 days, Max 400mg)
Lorazepam 1-2mg
Do not give IM olanzapine and BZD together (at leasr 1 hr apart)
Repeat up to x2 at 30-60 minute intervals
Consider IV tx get expert help IV treatments Risks Over-sedation
Interaction with illicit drugs
Damage to therapeutic relationship
Prolonged QTc
EPSE - dystonic reaction
MNS Tx of oversedation with BDZ - Flumazenil
Tx of acute dystonic reaction - IM procyclidine Important to monitor vitals hourly at first A rare life threatening ideosyncratic reaction to antipsychotics.
Thought to be related to reduced dopamine activity and imparied Ca2+ mobilisation Aetiology Epidemiology Female : Male
2 : 1 Incidence = 0.07-0.2% Risk factors Clinical Signs Treatment Mortality 5-20%
Heart, resp or renal failure or DIC Restarting Anti-psychotics May be required
Stop anti-psychotics for 2/52 if possible.
Allow symptoms and signs to resolve completely Differential diagnosis Catatonia
Malignant hyperthermia
Serotone syndrome
Intoxicant use
Septic shock NMS vs. SS NMS SS Medication Antipsychotics Serotonin agonists Onset Slow (days-weeks) Rapid Slow (24-72hrs) Rapid Progression Muscle rigidity Activity Severe Less severe Reduced Increased Motivation Medication Haloperidol 5-10mg
Olanzapine 10mg
Chlorpromazine 50-100mg
Lorazepam 1-2mg
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