Er psych 2 10

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  • Intoxication, withdrawals from substances\nPsychiatric disorders\nPersonality disorders\nEnvironmental factors\nMedical disorders\n
  • Intoxication, withdrawals from substances\nPsychiatric disorders\nPersonality disorders\nEnvironmental factors\nMedical disorders\n
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  • Er psych 2 10

    1. 1. Emergency Psychiatry Wayne Nguyen, MD Matt Levin, MD Director of Psychiatry, CHOC
    2. 2. Aggression Verbal Aggression Physical Aggression Aggression against objects
    3. 3. Neurochemistry ofImpulsive Aggression Androgens Serotonin Vasopressin GABA Nitric Oxide Norepinephrine Dopamine
    4. 4. Neurochemistry ofImpulsive Aggression Androgens Serotonin Impulsive- Vasopressin Aggression GABA Nitric Oxide Norepinephrine Dopamine
    5. 5. Contributing Factors
    6. 6. Contributing Factors Neurological Disorders Psychiatric Disorders Genes Impulsive- Medical Gender Aggression DisordersEnvironment Substance Toxins Abuse
    7. 7. Case 13 year-old autistic male here for surgical repair of pectus, now yelling, throwing things at nurses
    8. 8. Initial Approach To TheAgitated/Assaultive PatientCall securityAssess Environment, Physical demeanorTake verbal threats seriouslyRemain several feet awayKnow where the patient is at all timesClear the area of other patientsRemain calm, maintain confident andcompetent demeanorAvoid arguing with staff in front of patientRestraints
    9. 9. Non-Pharmacologic InterventionsJaacap, Agitation Treatment for Pediatrics
    10. 10. CHEMICAL RESTRAINT Involuntary use of psychoactive medication in a crisis situation to help a patient contain out-of-control aggressive behavior Necessary for safety of patient and staff when other methods of calming are inappropriate or not successful Parental consent not required due to emergent circumstances IM/IV/PO 8
    11. 11. Symptom Focused TreatmentWith Medication Treatment provided with the consent of the patient’s legal guardian and the age-appropriate assent of the child Usually PO 9
    12. 12. Characteristics of Ideal MedicationUsed for Acute Aggression Rapid onset Medium-long duration Multiple formulations Low interaction with other medications Low adverse reactions Broad anti-aggressive property
    13. 13. Pharmacological Treatments Lorazepam - non-specific treatment IM/PO/IV 0.5-2mg 1-6 hours as needed Antipsychotics Haldol 1-5mg IM - akithisia, dystonia Olanzapine, Geodon, Abilify IM Risperidone 1-2mg PO, ODT M-Tab 0.5, 1, 2, 3, 4 mg doses Olanzapine 10-20mg PO, ODT Zydis 5, 10, 15, 20 mg doses
    14. 14. Medication Half-Lives
    15. 15. If already taking psych meds:
    16. 16. Specific symptoms treatment
    17. 17. General Agitation
    18. 18. Suggested dose ranges
    19. 19. Side Effects:Benzodiazepines Disinhibition Sedation Respiratory Suppression (Olanzapine Confusion Ataxia 17
    20. 20. Potential Short-Term Side-Effects: Antipsychotics Dystonic Reaction Treat with Benadryl 25-50 mg IM 18
    21. 21. Potential Short-Term Side-Effects: Antipsychotics Tardive Dyskinesia 19
    22. 22. Potential Short-Term Side-Effects: Antipsychotics Leukopenia Avoid if ANC < 1000 Close monitoring in immunosuppressed patients 20
    23. 23. Neuroleptic Malignant Syndrome (NMS) Idiosyncratic response to anti- psychotics Have been reported with all types of antipsychotics, including atypicals Prevalence - 0.07-0.2% 5-30% mortality Can occur within hours of the first dose but usually 4-14 days Caused possibly by decreased dopamine
    24. 24. Clinical Features Muscle rigidity Hyperpyrexia (>38) Altered Mental status - obtundation Autonomic instability - tachycardia, hyper/hypo tension Profuse diaphoresis Tremor Incontinence
    25. 25. Differential Diagnosis Delirium Tremens Encephalitis Meningitis Heat exhaustion/stroke Rhabdomyolysis Septic Shock Hemorrhagic Stroke Toxidromes
    26. 26. Other conditions Dystonic reaction Serotonin syndrome
    27. 27. Laboratory Studies CBC - leukocytosis CPK - elevated LFT’s - elevated Creatinine/BUN Serum and urine toxicology Consider CT, LP if indicated
    28. 28. Treatment Stop antipsychotic Consider other medical causes Supportive care, IV hydration Benzodiazepines (Ativan) Dopamine agonists - Bromocriptine, Levodopa Muscular skeletal relaxant - Dantrolene
    29. 29. Case Example 16 year-old oncology patient recently discharged from OICU after 4 month stay now in clinic with psychosis, agitation after being home for less than a week. No personal or family history of psychotic disorder.
    30. 30. Alcohol/Benzo Withdrawal Can occur 12-24 hours after last drink Tremor (“shakes”) Tachycardia, diaphoresis, anorexia, insomnia Generalized seizures after 1-3 days Delirium tremens after 3-5 days Fever, disorientation, visual hallucinations, autonomic instability, agitation Need to be monitored in ICU setting
    31. 31. Treatment Thiamine to prevent Wernicke Encephalopathy (confusion, ataxia, ophthalmoplegia) IV hydration Electrolytes replacement Benzodiazepines Librium (25-50 mg PO PRN) Lorazepam (1-2 mg PO PRN)
    32. 32. Delirium Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) Reduced ability to focus, sustain, or shift attention. A change in cognition (such as memory deficit, disorientation, language disturbance) Development of a perceptual disturbance The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
    33. 33. Treatment Treatment of the underlying cause Assessment of clinical status-harm to self or others Environmental manipulation (Calendar, Newspaper, Blinds opened/closed appropriately) Restraints Pharmacological Antipsychotics Haldol 0.5 – 5 mg po q6 prn (PO/IV/IM) Risperidone 0.5 – 2.0 mg po q6 prn (PO/SL) Benzodiazepines – not recommended
    34. 34. Treatment of Agitated Patient Treat any underlying medical pathology Non-Pharmacological Interventions Symptom Focused Treatment Chemical Restraint 33

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