Emergencies Caused By Psychiatric Drugs

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LIFE THREATENING EMERGENCIES ASSOCIATED WITH THE USE OF PSYCHIATRIC DRUGS

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Emergencies Caused By Psychiatric Drugs

  1. 2. Emergency caused by psychiatric medications side effects <ul><li>Serotonin syndrome </li></ul><ul><li>Neuroleptic malignant syndrome </li></ul><ul><li>Extrpyramidal reactions </li></ul><ul><li>Emergencies caused by tricyclics </li></ul><ul><li>Priapism </li></ul><ul><li>Hyperadrenergic crisis </li></ul><ul><li>Anticholinergic symptoms </li></ul><ul><li>Lithium toxicity </li></ul>
  2. 3. SEROTONIN SYNDROME EMERGENCY IN PSYCHIATRY
  3. 4. DANGERS OF SEROTONIN SYNDROME <ul><li>Serotonin syndrome is commonly misdiagnosed as a psychiatric disorder </li></ul><ul><li>The syndrome can be fatal if the drug causing is not discontinued </li></ul>
  4. 5. Mild Serotonin Syndrome <ul><li>Very common </li></ul><ul><li>Is seen even in patient taking one SSRI </li></ul>
  5. 6. Increase serotonin synthesis <ul><li>L-tryptophan </li></ul>
  6. 7. Decrease serotonin metabolism <ul><li>MAO inhibitor including segiline </li></ul>
  7. 8. Increase serotonin release <ul><li>Amphetamine, cocaine, MDMA </li></ul><ul><li>Fenfluramine (Pondimin) or decefenfluramine (Redux) </li></ul><ul><li>Reserpine </li></ul>
  8. 9. Inhibit serotonin uptake <ul><li>Tricyclic antidepressants </li></ul><ul><li>SSRIs </li></ul><ul><li>Dextromethoraphan </li></ul><ul><li>Mepeidine (Demerol) </li></ul><ul><li>Bupropion (Wellbutrin, Zyban) </li></ul>
  9. 10. Serotonin receptor agonists <ul><li>Buspirone (Buspar) </li></ul><ul><li>LSD </li></ul><ul><li>Sumatriptan (Immitrex) </li></ul>
  10. 11. Nonspecific increase in serotonin levels <ul><li>ECT </li></ul><ul><li>Lithium </li></ul><ul><li>Dopamine agonists </li></ul><ul><li>Amantadine (Symadine)-Bromocriptine-Levodopa </li></ul>
  11. 12. Risk of using Paroxetine (Paxil) <ul><li>Paroxetine is the most likely to cause this syndrome particularly when used in combination with dextromethorphan </li></ul>
  12. 13. Behavioral symptoms of serotonin syndrome <ul><li>Confusion </li></ul><ul><li>Agitation </li></ul><ul><li>Anxiety </li></ul><ul><li>Coma </li></ul>
  13. 14. Autonomic symptoms of serotonin syndrome <ul><li>Fever </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Tachycardia </li></ul><ul><li>Hypertension </li></ul><ul><li>Diarrhea </li></ul>
  14. 15. Neuromuscular symptoms of serotonin syndrome <ul><li>Myoclonus </li></ul><ul><li>Hyperreflexia </li></ul><ul><li>Muscular rigidity </li></ul><ul><li>Ataxia </li></ul><ul><li>Restlessness </li></ul><ul><li>Shivering or tremors </li></ul>
  15. 16. Diseases predisposing to serotonin syndrome <ul><li>1. Complex psychiatric syndrome such as obsessive-compulsive disorder </li></ul><ul><li>2. Treatment of bipolar syndrome. These conditions need treatment with several serotogenic agents </li></ul><ul><li>Use of Fluoxetine needs longer time for washout when switched to another SSRI </li></ul><ul><li>Anti-parkinsonian medication as selegeline (Eldepryl) are at risk </li></ul>
  16. 17. Treatment of serotonin syndrome <ul><li>Discontinuing all serotonin drugs is the first step, and in milder case, it is often sufficient </li></ul><ul><li>For mild outpatient cases, treatment with oral lorazepam is often beneficial </li></ul>
  17. 18. Medications of serotonin syndrome <ul><li>Periactin (Cyproheptadine) is a specific blocker of the serotonin </li></ul><ul><li>Propranolol is also a specific blocker of the serotonin </li></ul><ul><li>Methysergide is also reported to successfully treat serotonin syndrome </li></ul>
  18. 19. Treament of severe serotonin syndrome <ul><li>Should be treated in an inpatient intensive care setting </li></ul><ul><li>In more severe cases, intravenous lorazepam in relatively high doses are effective </li></ul>
  19. 20. TREATMENT OF SEROTONIN SYNDROME Refractory or severe cases Cryoheptadine 4 mg PO q 6 hrs Propranolol (Inderal) a mg IV q 30-60 min or 40mg PO q 6 hrs Methysergide (Sansert), 2 mg PO TID Lorazepam, 1 to 3 mg IV q 20-30 min up to 16 mg per day Mild cases Lorazepam (Ativan) 0.5-1.0 mg orally q 4-6 h Cryoheptadine (Periactin), 4 mg PO q6 h
  20. 21. EMERGENCIES CAUSED BY PSYCHIATRIC DRUGS Neuroleptic Malignant Syndrome
  21. 22. DRUGS CAUSING NMS <ul><li>1. Neuroleptic medications </li></ul><ul><li>2. MAO inhibitors </li></ul>
  22. 23. Differences in manifestations of NMS from serotonin syn <ul><li>Patients with NMS are more likely to present with fever, extreme muscle rigidity (Lead pipe), severe extra pyramidal symptoms, elevated creatinine kinase and liver enzyme level </li></ul><ul><li>NMS occurs after taking Neuroleptic medication for some time </li></ul><ul><li>Serotonin syndrome starts immediately after starting serotonergic drugs </li></ul>
  23. 24. Similarities of NMS and serotonin syndrome <ul><li>There are many manifestations of serotonin syndrome are same as NMS. </li></ul><ul><li>Many experts consider NMS as a more extreme case of serotonin syndrome </li></ul>
  24. 25. Extra pyramidal Reactions Difficult to treat Involuntary movements of face, trunk and extremities -often irreversible c Tardive dyskinesia Antihistamines Anticholineric Inability to sit still C Akinesia Beta blockers Inability to sit still B Akathisia Anticholinergic Rigidity, decreased movements, abnormalities in gait B Parkinsonism Antihistamines Anticholinergic Neck and facial muscle spasm; Oculogyric crisis a Dystonia Treatment Symptoms Ac Ch Condition
  25. 26. Clinical manifestations of Dystonia <ul><li>An acute dystonic reaction is a frightening syndrome that involves uncontrollable spasms of neck and facial muscles </li></ul><ul><li>The patient may present with extreme torticollis </li></ul><ul><li>If the ocular muscle are involved, the gaze may be fixed upward in Oculogyric crisis </li></ul><ul><li>Respiratory compromise occurs if the larynx in involved </li></ul>
  26. 31. generalised dystonia
  27. 33. Clinical manifestations of Parkinsonism reaction <ul><li>Parkinsonian reactions are common in patients who take neuroleptic agents </li></ul><ul><li>Common Parkinsonian symptoms are rigidity, decreased movements, abnormalities in gait and balance </li></ul><ul><li>Patients with this reaction rarely present with cases requiring urgent care </li></ul><ul><li>Symptoms usually develop gradually with chronic use </li></ul><ul><li>Treatment with anticholinergics typically controls symptoms </li></ul>
  28. 34. Clinical manifestations of Akathisia <ul><li>Patient can come with symptoms in emergency </li></ul><ul><li>Is characterized by restlessness </li></ul><ul><li>Inability to sit still </li></ul><ul><li>Occurs in high percentage of patients who take neuroleptics </li></ul><ul><li>Patients begin pacing or develop extreme agitation </li></ul><ul><li>The syndrome is difficult to treat </li></ul><ul><li>Anticholinergics are not effective, but beta blockers in doses up to 120 mg per day may be effective </li></ul>
  29. 37. Clinical manifestations of Akinesia <ul><li>Akinesia is a syndrome of apathy that usually develops slowly </li></ul><ul><li>Many symptoms may simulate the negative symptoms of schizophrenia </li></ul><ul><li>Treatment of Anticholinergics may be effective </li></ul>
  30. 39. Clinical Manifestations of Tardive dyskinesia <ul><li>Tardive dyskinesia is a disorder characterized by involuntary movements of the face, trunk and extremities </li></ul><ul><li>Tardive dyskinesia is often irreversible </li></ul><ul><li>In addition to the neuroleptics, the drugs like metoclopramide may cause TD </li></ul><ul><li>TD is difficult to treat and rarely presents in emergency </li></ul><ul><li>Patient should be informed and his written consent should be obtained for the long term use of neuroleptics due to TD </li></ul>
  31. 41. Emergency caused by the use of tricyclics <ul><li>Cardiac-Conduction block </li></ul><ul><li>- SA nodal dysfunction </li></ul><ul><li>Seizures </li></ul><ul><li>Glaucoma </li></ul><ul><li>Urinary retention </li></ul><ul><li>Anticholinergics syndrome </li></ul>
  32. 42. Priapism- an emergency caused by Trazodone <ul><li>Priapism is a persistent painful penile erection, has been associated with neuroleptic therapy </li></ul><ul><li>Is most commonly caused by Trazodone </li></ul><ul><li>This is an emergent condition because impotence may occur without immediate treatment </li></ul>
  33. 43. Anticholinergic syndrome <ul><li>This condition is most often associated with the use of tricyclics antidepressant, neuroleptics and benztropine </li></ul><ul><li>Sighs and symptoms of Anticholinergic syndrome-Tachycardia, Dilated pupils, Warm dry skin, Fever, Agitation, Confusion, Hallucinations, Delirium and Seizures </li></ul><ul><li>Treatment should be directed at symptoms and use of anticholinergic should be discontinued </li></ul><ul><li>Physostigmine is useful, but the use is not recommended because of potential serious side effects </li></ul>
  34. 44. Hyper adrenergic crisis <ul><li>Hyper adrenergic crisis is characterized by severe headaches, diaphoresis and hypertension </li></ul><ul><li>This condition is caused by concurrent use of MAO inhibitors and tyramine containing foods and sympathomimetic agents </li></ul><ul><li>Phentolamine and chlorpromazine have been traditionally used, nifedipine has been shown to be the most effective treatment </li></ul>
  35. 45. Lithium toxicity <ul><li>Levels between 2 and 3 mmol per L produce mild symptoms such as GI upset, tremor or drowsiness </li></ul><ul><li>Levels greater than 3 mmol per L can cause serious toxic reaction such as confusion, ataxia, seizures and coma. May result in death. </li></ul>
  36. 46. Conclusion <ul><li>Psychiatric medications are associated with variety of side effects, some of them are serious and can be life threatening </li></ul><ul><li>When psychiatric patient under treatment present with different signs and symptoms, the adverse drug effects should be considered in the differential diagnosis </li></ul>
  37. 47. Syndromes associated with the use of psychotherapeutic agents <ul><li>Serotonin syndrome </li></ul><ul><li>Neuroleptic malignant syndrome </li></ul><ul><li>Extra pyramidal syndromes </li></ul><ul><li>Cardiac symptoms </li></ul><ul><li>Seizures </li></ul><ul><li>Glaucoma and urinary retention </li></ul><ul><li>Priapism </li></ul><ul><li>Hyper adrenergic crisis </li></ul><ul><li>Anti- cholinergic syndromes </li></ul><ul><li>Lithium toxicity </li></ul>

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