Emergency Medicine Understanding Of Psychosis

Dr. Nawaf Al Amri M.DSaudi Board Of Emergency Medicine

Psychosi

s

We Are Going To Cover ..

- Introduction .

- Historical Progression Of Psychosis Management .

- Presumed Attitude Of Emergency Medicine .

- General Look Into Psychosis & Its Elements .

- Clinical Assessment & Management .

- Deferential Diagnosis .

- Referral & Consultation .

- Disposition & Follow-Up .

Introduction- Noncompliance with antipsychotic medication remains a leading cause of psychiatric

hospitalization.

- Mental health–related visits to U.S. EDs increased 38% from 17.1 to 23.6 per 1000 U.S. population (p <.001). “ Compare Mental Health Related In KSA ‘’

- Mental health problems have been documented as the primary reason for the visit in 6.3% of all ED attendances, but covert mental health problems may be present in over a third of all ED patients. ‘’ Obscurity Of Visit Here In KSA ‘’

- Because there are approximately 3800 general EDs in the U.S. and only 146 psychiatric EDs, the vast majority of acute behavioral problems are assessed and treated in general hospital EDs. ‘’ What's The ER To Psych Ratio in KSA ? ‘’

- The closure of psychiatric inpatient facilities, reductions in inpatient beds, moves to treat people in the community, and increased out-of-pocket costs for mental health visits have coincided with, and likely contributed to, increased visits to EDs by psychiatric and suicidal patients who previously would have been admitted or seen in other settings. GO TO ER

^_^ Lets Go To ER ^_^

So how were they treated before ?

No matter how bad your management is …

you wont do worse than what these guys did over the past couple of years

Lets Watch ..

The Historical Progression Of Psychosis Treatment

• Barbequing ( Medieval Days )


• Ice Water Immersion ( 1890 ) “ Talk about progressive thinking Huh !! “


• Malarial Therapy for The Insane (1917)


• Barbiturate-Induced Coma Therapy (1920)


• Insulin Shock Therapy (1933)


• Cardiazol Shock Therapy (1934)


• Lobotomy (1936) That Guy Received A Nobel Prize !?


• Electroconvulsive Therapy (1938)


• Chlorpromazine ( 1954 )

How Do We Usually Feel Towards These Kind Of Patients ?

، هيه يا تختور ، فيه نفس

فيه عين ، محسود ، فيه

مس ، ملبوس بجني ، ما

ه يذوق العيشه ، نباله غذاي

، وفحوصات ، و شيعوه ،

واعطوه ادويه باإلبره

الحبوب ما تنفع وبسرعه

ترا لنا نص ساعه ننتظر

!!

Attitude Of Emergency Staff- What’s the current attitude from Emergency Staff , Nurses , Security ,

Unit Assistants & More importantly EMERGENCY PHYSICIANS ?

- Given that psychiatric visits to EDs are increasing and that mental health patients frequently have few alternatives available beyond the ED safety net … So .. ?! ( NO WHERE TO GO BUT ER )

- It is important that emergency providers resist the temptation to dismiss these patients as nuisances or "frequent fliers" who "abuse the system “ … (( TAKE CARE OF YOUR FREQUINT FLYERS ))

- Many mental health patients in the ED have previously exhausted their psychosocial support and the goodwill of relatives, family, and even mental health care workers. (( FED UP WITH PSYCH .. ))

Attitude Of Emergency Staff- Their poor hygiene, homelessness, and/or repeated presentations to EDs

are often both a cause and a consequence of this alienation in the ED as well. “ Rather Take Care Of A Pneumonia Or Sepsis ?! “

- Staff may see difficult psychiatric patients who present repeatedly as unwelcome and fodder for gallows humor; their frustration notwithstanding, ED staff must resist their own feelings of alienation, because these may lead to dismissal of legitimate patient needs and less than thorough assessments at each visit. “ Take The Chart , Don’t Avoid ! “

- One way to remain vigilant and mindful of professional duties to patients is to promote an ED attitude of Unconditional Positive Regard and Non-Judgment Approach as an important preventive measure against alienation.

- Non-judgment has been described as a cardinal virtue for physicians ministering to patients in crisis. “ Don’t Take It Personal , it’s Ur Job ?! “

Definition Of Psychosis

- Psychosis is a state of severe mental disorder with loss of contact with reality

- Usually including false beliefs about what is taking place or who one is (delusions) and seeing or hearing things that aren't there (hallucinations)

- Characterized by derangement of personality and causing deterioration of normal social functioning , with or without organic damage .

- Psychosis is a nonspecific syndrome, and careful evaluation is required to differentiate between psychiatric and organic origins

Elements Of Psychosis

• 1- Delusions

• 2- Hallucinations

• 3- Disorganized Though And Speech

• 4- Grossly Disorganized or Catatonic Behavior

• 5- Aggressive , Regressive Or Indifferent Physical & Mental State Ass. With Poor Functionality .

N.B : They don’t need to be all together to call it psychosis , cause psychosis is a spectrum ..

Definition Of Delusions

• Three main criteria for a belief to be considered delusional :

1- Certainty (held with absolute conviction)

2- Un-amenable To Reason (not changeable by compelling counterargument or proof to the contrary)

3- Impossibility or falsity of content (implausible, bizarre or patently untrue)

- Furthermore, when a false belief involves a value judgment, it is only considered as a delusion if it is so extreme that it cannot be or ever can be proven true (example: a man claims that he flew into the sun and flew back home. This would be considered a delusion).

Capgras Delusion

Is a disorder in which a person holds a delusion that a friend, spouse, parent, or other close family member has been replaced by an

identical-looking imposter .

Fregoli Delusion

A rare disorder in which a person holds a belief that different

people are in fact a single person who changes appearance

or is in disguise & can also inaccurately replicate places,

objects, and events.

Control Delusion

A false belief that another person, group of people, or external force controls one's general thoughts, feelings, impulses, or behavior.

Nihilistic Delusion

This is a false belief that one does not exist or has become deceased.

Delusion Of Infidelity

delusional jealousy where person with this delusion falsely believes that a person is lying to them or that a spouse or

lover is having an affair, with no proof to back up their claim.

Delusion Of Guilt

This is a false feeling of remorse or guilt of delusional intensity.

Thought Broadcasting And Mind Reading Delusions

false belief that other people can know one's

thoughts telepathically or that one’s thoughts are

being broadcast to others without owns will

Delusion Of Reference

The person falsely believes that insignificant remarks, events, or

objects in one's environment have personal meaning or

significance.

Erotomaniac Delusion

A delusion where someone believes another person is in

love with them.

Grandiose Delusions

Sufferer does not have insight into his loss of touch with reality

and is convinced he has special powers, talents, or abilities,

Sometimes, the individual may actually believe they are a famous

person or character

Religious Delusion

Think They Are Gods , Spoke To God Or Are People

Who Know God Or They Are Friends With Them .. Etc

Somatic Delusion

A delusion whose content pertains to bodily functioning, bodily sensations, or physical appearance. Usually the false belief is that the body is somehow diseased, abnormal, or

changed— for example, infested with parasites.

Delusions Of Parasitosis

In which one feels infested with an insect, bacteria, mite, spiders, lice, fleas, worms, or

other organisms. Affected individuals may also report being repeatedly bitten & sometimes physical manifestations may

occur including skin lesions.

Delusion Of Poverty

The person strongly believes that he is financially incapacitated. Although this type of delusion is less

common now

Persecutory Paranoid Delusions

The most common type of delusions and involve the theme of being followed, harassed, cheated,

poisoned or drugged, conspired against, spied on, attacked, or obstructed in the pursuit of goals.

Definition Of Hallucinations

• A hallucination is a perception in the absence of a stimulus.

Defined as perceptions in a conscious and awake state in the absence of external stimuli which have qualities of real perception, in that they are vivid, substantial, and located in external objective space.

Types Of Hallucinations

Hallucinations can occur in any sensory modality:

Visual , Auditory , Olfactory , Tactile , Gustatory Proprioceptive & Equilibrioceptive , Nociceptive

Thermoceptive and Chronoceptive.

Visual Hallucinations

Auditory Hallucinations

Olfactory Hallucinations

Tactile Hallucinations

Gustatory Hallucinations

Proprioceptive & Equilibrioceptive Hallucinations

Nociceptive Hallucinations

Thermoceptive Hallucinations

Chronoceptive Hallucinations

Thought Disorder

• Affected persons show loosening of associations, that is, a disconnection and disorganization of the semantic content of speech and writing.

• shifting randomly from one topic to another without a logical connection.

• Neologisms (nonsense words invented by the patient) and perseverations (frequently repeated words or phrases) are common.

• In the severe form speech becomes incomprehensible and it is known as "word-salad".

Do You Have TP For My Bungoholio ?

Catatonia• Motor Catatonia :

• Involves excessive and purposeless motor behavior as well as extreme mental preoccupation which prevents intact experience of reality.

• Waxy Catatonia :

• No movement or interaction with the world in any way while awake while moving part body and the person stays in the position even if it is bizarre and otherwise nonfunctional , no reaction to anything that happens outside of them.

• Rigid Catatonia :

• Resisting active or passive movement , with no reaction to any external stimuli however strong that stimuli is .

Negative And Positive Symptoms

- Negative Symptoms ( Premorbid phase ) :

1- Flattening of affect : little facial expressiveness, eye contact, or body language.

2- Alogia : poverty of speech, is manifested by brief, laconic, empty replies to questioning.

3- Avolition : inability to initiate and persist in goal-directed activities.

Similar symptoms may be found in patients with severe depression, chronic environmental understimulation, and treatment with neuroleptic medications.


- Positive Symptoms ( Active Phase ) :

Precipitated by a stressful event Or D/C medications .

1- Active Delusions & Hallucinations

2- Bizarre behavior

3- Agitation & Hyper vigilance

4- Withdrawal state characterized by rocking or staring.

It is during this phase that they are most likely to be brought to the emergency department by family, friends, coworkers, or the police.


- Residual Symptoms ( Residual Phase ):

1- Impaired social and cognitive ability.

2- Bizarre ideation.

3- Delusions.

4- Peculiar behavior,

5- Poor personal hygiene

6- Social isolation.

7- Psychotic decompensation.

Smells Like Schizophrenia ?

• It’s a diagnosis of exclusion in Psychiatry so it shouldn’t be your primary diagnosis in ER .

• Rule out Organic and Systemic causes , leave the final diagnosis for the Psych PPL .

• Is it a whole other game if the patient is ALREADY dx with a Mental Disorder without a clear cause that precipitated the presentation ?

Subtypes Of Psychosis

• Brief psychotic disorder: due to acute stress , lasting from 1 day to 1 month, with an eventual return to the premorbid level of functioning .

• Schizophreniform psychosis: psychosis which can be triggered by an extremely stressful event in life , lasting from 1 day to 6 months , may progress to full Schizo .

• Brief reactive psychosis: psychosis which can be triggered by an extremely stressful event in life .

• Manic-depressive psychosis: bipolar disorder, especially the manic episodes thereof, can include psychotic features.


• Mystical psychosis: a term coined to characterize first-person accounts of psychotic experiences that are strikingly similar to reports of mystical experiences .

• Menstrual psychosis: abnormal behavior linked to menstruation

• Myxedematous psychosis: a relatively uncommon consequence of hypothyroidism or patients who have had the thyroid surgically removed


• Stimulant psychosis: a psychotic disorder that appears in some people who abuse stimulant drugs

• Substance-induced psychosis: a form of substance-related disorder where psychosis can be attributed to substance use

• Tardive psychosis: a form of psychosis distinct from schizophrenia and induced by the use of current (dopaminergic) antipsychotics by the depletion of dopamine and related to the known side effect caused by their long-term use, tardive dyskinesia .


• Shared psychosis: psychiatric syndrome in which symptoms of a delusional belief are transmitted from one individual to another

• Occupational psychosis: the concept that one's occupation or career makes that person so biased that they could be described as psychotic

• Postpartum psychosis: a group of mental illnesses with the sudden onset of psychotic symptoms following childbirth


• SLE psychosis: as a progressive manifestation of SLE or as a result of corticosteroid use .

• Marijuana psychosis: panic, paranoia, or acute psychosis, particularly with novice users or individuals with preexisting psychiatric disease , episodes are usually transient and reality testing remains intact.

• Korsakoff psychosis: alcohol-induced persisting amnestic disorder, is a disorder with recent memory impairment, inability to learn new information or recall previously learned information, apathy, and confabulation.


• Delirium psychosis: Which has to states , hyperactive acute confusional state associated with increased alertness, increased psychomotor activity, and disorientation and is often accompanied by hallucinations , hypoactive is the exact opposite of the previous state

• Depression psychosis: Comes in severe depression where patient alters between 2 sides of delusion and hallucinations one related to depression and the other isn’t


• Mood disorder with psychotic features : psychosis present only during periods of mood disturbance .

• Schizoaffective disorder: if psychosis persist longer than 2 weeks in the absence of prominent mood symptoms.

• Ganser’s syndrome: emotional in origin in which the patient may appear to have amnesia, hallucinations, or alterations in consciousness, usually in association with physical complaints for no apparent gain except to assume the role of the psychiatric patient.

Do I assume all psychotic presentations to be of pure psychiatric disorder ?

• Patients with Known Psychiatric Disorders :

- Mild to moderate exacerbation of their symptoms do not require extensive laboratory evaluation.

- Severe exacerbation of symptoms accompanied by marked agitation, violent behavior, or significantly abnormal vital signs should receive more extensive evaluation.

- May have coexisting substance abuse or undiagnosed medical disorders; thus, a complete history and physical examination, including routine toxicology studies, are indicated for most patients.

Do I assume all psychotic presentations to be of pure psychiatric disorder ?

• Patients without Known Psychiatric Disorders :

- Many toxicological and medical disorders can mimic or cause Acute Psychosis.

- These patients deserve to be worked up for ( systemic , organic , toxicological … etc ) causes of psychosis before assuming it as a pure psychological issue .

- Do not fall in the pitfall of putting psychiatric illness in the top of your differential diagnosis

Organic Vs. Functional ?

Don’t Miss These In Your Initial Assessment &

Workup

General Approach

Step Comment

Safety and stabilization

Contain violent and dangerously psychotic persons to provide a safe environment for staff, patients, family, and visitors while simultaneously attending to airway,

breathing, and circulation.

Identification of homicidal, suicidal, or other dangerous behavior

Determine if the patient needs to be forcibly detained for emergency evaluation.

Medical evaluation

Determine the presence of any serious organic medical conditions that might cause or contribute to abnormal

behavior or thought processes (e.g., hypoglycemia, meningitis, drug withdrawal, or other causes of

delirium).

Psychiatric diagnosis and severity assessment

If the behavior change is not due to an underlying medical condition, it is primarily psychiatric or

functional, requiring a psychiatric diagnosis and assessment of the severity of the primary psychiatric

problems.

Psychiatric consultation Determine the need for immediate psychiatric

consultation.

Safety First !!

• 10% of psychiatric patients in the ED exhibit violent behavior >> may need physical or chemical restrain.

• Violent & aggressive behavior demands immediate restraint to protect the patient, other patients, staff, and visitors.

Safety First !!

• Hospital security forces and police are often available to subdue violent patients and reduce risks of staff or patient injury ? Yeah Right

• ED staff must be educated and equipped with skills including enhanced awareness of risk factors and warning signs of violent behavior, verbal de-escalation techniques, quick access to rapidly tranquilizing or neuroleptic medications . وين الباب بس ؟

Safety First !!

• If necessary such patients should be :

• Isolated

• Restrained

• Disrobed

• Gowned

• Searched for weapons.

Safety First !!

- Stay distant from the patient, avoid excessive eye contact, maintain a somewhat submissive posture and tone of voice, and stand in a location that neither threatens the patient nor blocks the exit ( Body Language ) .

- Allow patients to verbally ventilate feelings and make neutral comments, physicians may defuse potentially violent situations. ( Let Them Vent )

- Adequate force nearby should be visible to the patient, and the patient should clearly be told that uncontrolled behavior will result in restraint ( show them whos boss )

Alarming Sings !!

• Manifested violent behavior

• Physically or verbally threaten staff

• Demonstration of an escalating level of agitation despite verbal attempts to calm them.

- If you notice any of these , and you still think you need to do physical examination before doing something about it .. Ur getting a kick , a punch or a spit .. Enjoy !!

Restraints

• In many cases, there is no substitute for the safe application of physical limb restraints, despite misinformed guidelines attempting to limit their use.

• The patient should be reassured that this action is being undertaken for the patient's benefit. A team of five staff members is recommended

• Sometimes, the show of force and the presence of many staff may in itself be sufficient to subdue the patient without recourse to restraints.

Restraints

• Sometimes, the show of force and the presence of many staff may in itself be sufficient to subdue the patient without recourse to restraints.

• Importantly, the patient's head should be elevated to minimize risk of aspiration.

• Once restrained, the patient should be offeredmedications, and if these are refused, they should be administered involuntarily

Examination Room

• Seclusion rooms may be used.

• Rooms should be designed to be safe, and objects that could be used in violent attacks of self-injury or against staff should be removed from room and pt .

• The patient should be advised of the consequences of his or her violent behavior.

Examination Room

• The patient must be given opportunities to comply with staff demands for acceptable behavior and release from seclusion.

• If violent behavior persists, the use of physical restraint is justified. All steps in the use of seclusion and medical and physical restraints should be documented.

Medical Evaluation

Document behavioral changes through history.

Identify medical symptoms.

Determine medical comorbidities.

Obtain medication and drug history.

Perform physical examination.

Perform neurologic examination.

History

- Should be taken as if it was from any other pt .

- Obtaining information on recent changes in behavior from the patient and from caregivers and family members.

- Compare direct observations of the patient's behavior with reports from the patient's family and caregivers.

- During the examination the patient's affect or outward display of emotion should be evaluated for sadness, euphoria, and anxiety.

History

- Sudden onset of major changes in behavior, mood, or thought in a previously normal patient, or definite deterioration in a patient with a chronic behavioral disorder, should stimulate evaluation for an underlying medical or neurologic disorder.

- Any initiation of substance abuse or changes in the patterns of abuse as well as any changes in adherence to the medication regimen or in the level of previous functioning should be determined.

History

- Define social stressors from family and compare with pt

- Visual hallucinations can occur in functional psychotic illnesses (schizophrenia or affective disorder), but most often result from organic disease.

- A patient with visual hallucinations should be assumed to have organic pathology until proven otherwise.

History

• The examiner should be sitting, and if possible the interview should proceed to completion without interruption.

• If the patient is believed to be potentially dangerous but is not in need of immediate restraint, the interview should take place in an open area with security personnel nearby.

• The emergency physician should begin with an introduction and should express the desire to be “of help” to the patient. The interview should begin with open-ended questions designed to assess the patient’s complaint and understanding of the current circumstances.

History

• Good opening questions include :

• “Do you understand why you have been brought here ?

• “You seem to be upset. Can you tell me why?”

• “Do you have any idea why you might be having these symp-toms?”

• The patient’s appearance, body language, affect, and speech should be observed during the responses to these questions.

Neuro History ( VIP ) Most Senstive

• Full Neuro History should be obtained

• A brief mental status examination should be performed. It may be initiated in a nonthreatening manner by stating :

• “I am now going to ask you a few questions to see how well you are concentrating.”

MMSE : Testing Higher Functions

Medical Comorbidities

• Medical comorbidities must be identified, because psychiatric patients often develop medical illnesses that produce changes in behavior.

• It is necessary to ask specifically about fever, head trauma, immunocompetence (including malignancies and risk factors for HIV, diabetes, pulmonary diseases, and toxic ingestions or overdose.

Alcohol or Substance Abuse

• Patients with chronic mental illness have a higher incidence of alcohol and substance abuse than the general population.

• The syndromes associated with alcohol and substance abuse that can result in altered behavior include intoxication, withdrawal, delirium, hallucinosis, paranoid behavior, and dementia.

Physical Examination

• A limited physical examination should be conducted on every patient.

• Vital signs, including temperature, should be measured for all psychiatric patients.

• Abnormal vital sign values should not automatically be dismissed as secondary to anxiety or stress, but should be investigated.

• Fever is especially important, because both local and systemic infections can cause altered mental status, as can meningitis, encephalitis, and brain abscess.

• Neuroleptic malignant syndrome causes very high fevers, sometimes in excess of 40.6°C (105°F), and is an important life threat to recognize early in evaluation, because rapid treatment with dantrolene can be lifesaving.

Physical Examination

• Patients with abnormal vital sign values, abnormal mental status examination results, psychosis, or mental retardation as well as elderly patients usually require a more complete physical examination, including assessment of chest, heart, and abdomen.

• All patients should be examined for signs of trauma

• Examine integument for skin rash, extremity trauma, and needle tracks.

• FULL Neurologic examination typically includes an assessment of most cranial nerves and a thorough examination of the eyes, gait, mental status, and general motor function and strength.

Workup

• CBC , Electrolyte , LFTs , TSH , Gluco-Check , Coag Profile , ABG , Ammonia , Osmolarity , B12 , Folate , Lead Level , Adrenal Function , CK , Urine Myo

• Septic Workup ?

• Serum levels of certain medications :

• Lithium , Valproic acid, Phenytoin, Carbamazepine, phenobarbital acetaminophen, aspirin, digoxin, and cyclosporine

• Tox Screen , Ethanol Level ?

• ECG , CXR , Possibly Brain CT , LP

Diagnostic Imaging

• CT and related brain imaging should be considered if a clear change in behavior or an organic intracranial cause is suspected.

• Indicated in cases of :

• Altered mental status accompanied by fever

• New headache

• Focal neurologic findings

• Traumatic brain injury,

• Pt at risk for subdural hematoma.

• Immunocompromised patients and those who have altered mental status accompanied by fever, meningeal signs, and/or headache frequently need both a CT scan to rule out an abscess or mass as well as a lumbar puncture.

Treatment

- AFTER ABC & Addressing the presentation …

- ER pharmacological modalities :

- Rapid Tranquilizers

- Benzodiazepines

- Neuroleptics

Rapid Tranquilizers

• An ideal sedative for rapid tranquilization:

1- Easily administered .

2- Rapid onset of action .

3- Well tolerated .

4- Good side effect profile .

5- No addictive properties .

Rapid Tranquilizers

• Rapid tranquilization carries potential risks:

1- Excessive sedation

2- Aspiration

3- Adverse hemodynamic effects

4- Allergic reactions.

Rapid Tranquilizers

• Involves serial doses of a high-potency antipsychotic agent until target symptoms, such as agitation and excessive psychomotor activity, are improved.

• The goal is : to facilitate cooperation of the patient without causing unnecessary sedation, which would inhibit further medical and psychiatric assessment.

• PO , IM , IV doses can be given every 30 to 60 minutes until the patient becomes calmer and more cooperative.

• PO Vs. IM ?? >>> = Same onset and duration

HALOPERIDOL

• Haloperidol :

• Dose : 5-10 mg IM >> 0.5-2 mg in old ppl

• Reduces agitated phase but psychotic aspect is still present

• IV rout is not encouraged as it is associated with sudden death .

DROPERIDOL

• Droperidol :

• Dose : 2.5 – 5.0 mg IM

• Sedates more , Faster onset , shorter duration than halo.

• Associated more with prolonged QT , torsade , and sudden death more than halo

Rapid Tranqs

Droperidol and haloperidol are not recommended for use in patients who are

known or suspected to have cardiac arrhythmias or QT prolongation .

Neuroleptics

• Not encouraged to use as a sole agent in management of acute psychosis in ER Setting .

• Typical Vs Atypical Neuroleptics :

• Ziprasidone , Aripiparzole , Olanizipine are the newest atypicals , can be used IM

• Olanzapine and ziprasidone are not recommended for use in patients with a history of dementia.

Ziprasidone

• Dose : 20 mg IM , can be repeated Q 4 H .

• Has more sedation that halo with fewer EPS

• In general Antipsychotics are not usually used in ER and ER Staff usually don’t prescribe it to patients without a psychiatrist on call evaluation

Benzodiazepines

• IM routes of administration are preferred for patient and provider safety despite minor delays in the onset of action.

• Most effective in management of agitated patients , alcoholics or patients with sedative hypnotic withdrawals , cocaine or contraindication to Neuroleptics .

• Disadvantages :

1- higher risk of respiratory distress

• 2- need to repeat the dose

Benzodiazepines

• Lorazipam ( ATIVAN ) :

• 1 – 2 mg , sometimes given with halo or neuroleptics .

• Notes : Benzos can treat catatonia as well ..

So Aside from their psychotic issue

How can psychotic patients present to us other than the exacerbation of their

current illness

THEIR MEDS

Side Effects Of Antipsychotic Medications

1- Acute Dystonia ( Most Common )

2- Akathisia or Restlessness

3- Pseudoparkinsonism and Akinesia

4- Anticholinergic Syndrome

5- Orthostatic Hypotension

6- Arrhythmias

7- Tardive Dyskinesia

8- Neuroleptic Malignant Syndrome

9- Agranulocytosis

Side Effects Of Antipsychotic Medications

- General rules in antipsychotic side effects :

- High-potency neuroleptics tend to cause :

* Acute dystonia, Akathisia, and Parkinsonism .

- Low-potency neuroleptics tend to cause :

*Anticholinergic and Antiadrenergic effects .

- Dose and Age related side effects are associated more with :

* Anticholinergic and B-blocking effects .

Acute Dystonia

- Acute dystonia, the most common adverse effect seen with neuroleptic agents, occurs in 1 to 5% of patients.

- Occur at any point during long-term therapy and up to 48 hours after administration of neuroleptics in the emergency department.

- Involve the sudden onset of involuntary contraction of the muscles of the face, neck, or back.

Acute Dystonia

• The patient may also have :

1- Protrusion of the tongue (buccolingual crisis)

2- Deviation of the head to one side (acute torticollis)

3- Sustained upward gaze (oculogyric crisis)

4- Extreme arching of the back (opisthotonos)

5- Laryngospasm.

• These symptoms tend to fluctuate, decreasing with voluntary activity and increasing under emotional stress, which occasionally misleads emergency physicians to believe they are factitious , primary neurologic illnesses (seizures, meningitis, tetanus, etc.) or general patient restlessness.

Acute Dystonia

• Treatments :

1- Benztropine (Cogentin) :

-Dose : 1 – 2 Mg

2- Diphenhydramine (Benadryl) :

-Dose : 25 to 50 Mg

** For persistent reactions, both medications may be used, and benzodiazepines may be added for treatment failures.

Acute Dystonia

- Dystonias often recur despite dosage reduction or discontinuation of the offending antipsychotic.

- Patients should receive oral therapy with the same medication for 48 to 72 hours to prevent recurrent symptoms :

- Benztropine, 1 milligram PO two to four times daily, or diphenhydramine, 25 milligrams three times daily, should be continued for 3 days to prevent recurrence.

• Benztropine, diphenhydramine, and the older antipsychotic medications all cause anticholinergic effects, so combination therapy may worsen dry mouth, blurred vision, and urinary retention >>> Apptwith MRP

•

Akathisia or Restlessness

• Akathisia, a sensation of motor restlessness with a subjective desire to move

• Can begin several days to several weeks after initiation of antipsychotic treatment.

• Often misdiagnosed as anxiety or exacerbation of psychiatric illness >> Increasing Antipsych >> Vicious Circle … So evaluate well , see if there are any positive symptoms with that !!

• Aggravated by subsequent increases in antipsychotic dosage.

• Other coexisting signs : cogwheel rigidity , shuffling gait

Akathisia or Restlessness

• Treatments :

1- B-Blockers ( Propranolol ) :

- Dose : 30 to 60 Mg OD , May up to 90-180 Mg OD as BP allows .

2- Benztropine (Anticholinergic ) :

- Dose : 1 Mg two to four times Daily .

3- Benzodiazepines Or Glycine .

4- Decrease , Stop Or Change Antipsychotic .

Pseudoparkinsonism and Akinesia

• Antipsychotic-induced , indistinguishable from Parkinson’s disease, particularly in elderly patients during the first month of therapy.

• Includes : bradykinesia, resting tremor, cogwheel rigidity, shuffling gait, masked facies, and drooling, can occur

• Often only one or two features of the syndrome are obvious.

• Akinesia: immobility, withdrawal, and lack of motivation, may be mistaken for a postpsychotic depression.

• More often with high-potency neuroleptics .

Pseudoparkinsonism and Akinesia

• Treatments :

1- Self Limiting : will resolve in time

2- Benztropine (Anticholinergic ) :

- Dose : 1 Mg two to four times Daily .

3- Antiparkinsonians

4- Stop / Reduce Or Change Antypsychotic.

Anticholinergic Syndrome

* Peripheral manifestations :

- Dry mouth and skin

- Blurred vision

- Urinary retention

- Constipation

- Paralytic ileus

- Cardiac dysrhythmias

- Exacerbation of angle-closure glaucoma.

* Central manifestations:

- Dilated pupils

- Dysarthria

- Agitated delirium.

Anticholinergic Syndrome

• Treatment :

- Discontinuation of the antipsychotic and institution of supportive measures is the most prudent therapy.

Orthostatic Hypotension

• All the antipsychotic agents can cause orthostatic hypotension

• Related to anticholinergic and alpha-adrenergic blockade, and occur at therapeutic dosages.

• This complication is less common with the high potency agents .

Orthostatic Hypotension

• Treatments :

- Mild hypotension :

1- Oxygen

2- Trendelenburg’s position

3- IV crystalloid fluid administration

- Severe Prolonged Hypotension ( failing to respond to above ) :

1- Vasopressors ( Dopamine )

2- ICU On Board

** N.B : Agents with beta-agonist activity (e.g., epinephrine, isoproterenol) are contraindicated in these patients.

Tardive Dyskinesia

• Usually appears after several years of neuroleptic drug treatment , occurs in F more than M , More in typical Agents .

• Characterized by Involuntary movements of the face and tongue, that are described as writhing, grimacing, and choreoathetoid in nature.

• The earliest manifestation is often a curling or twisting move-ment of the tongue.

• The onset of these symptoms can be falsely attributed to psychological factors because they intensify under emotional stress, fatigue, and voluntary activity, and disappear with sleep.

Tardive Dyskinesia

• Treatment :

- Generally difficult and can mostly be permanent

* For Mild symptoms :

- D/C , Reduce Or Change Medication .

- Benzo .

* Moderate to Severe symptoms :

- Reserpine or Tetrabenazine .

- D/C Medication .

Dysrhythmias

• Most common cardiac effect is sinus tachycardia with a normal QRS duration

• If QRS prolongs , QT Prolongation and Torsades de Pointes , even in therapeutic dose .

• Associated with “ Highest To Lowest “ :

- Thioridazine >> Ziprasidone >> Risperidone >> Mesoridazine >> Droperidol>> Sertindole >> Olanzapine >> Quetiapine >> Haloperidol ..

* Antipsychotic medications with potential cardiac effects should not be used in patients with known congenital or medication-induced QTc prolongation.

Dysrhythmias

• Treatments :

1- Correction of hypokalemia, hypomagnesemia, and hypocalcemia.

2- Treatment of TDP includes :

- IV Mg sulf , overdrive pacing, and possibly isoproterenol.

* Administration of antiarrhythmic drugs that prolong the QT interval should be avoided.

Neuroleptic Malignant Syndrome

• A life-threatening complication of neuroleptic drug treatment that affects 0.5 to 1% of patients.

• Occurs in both typical and atypical agents .

• Usually occurs in the first few weeks after initiation of treatment, raising the dose or receiving I.V dose , exhaustion, dehydration.

• High fever , Severe muscle rigidity, Altered consciousness, Autonomic instability, Elevated CK , Respiratory failure, GI Bleeds, Hepatic & Renal failure, coagulopathy, CVS collapse.

• Can be confused with serotonin syndrome.


• Treatment :

- Recognition ( decreases mortality from 30% to Less Than 10 % )

- D/C Meds

- Fever Reduction : IVF & External Cooling

- Libral Rehydration with IVF & Urine Alkalization .

- Libral Amounts Of Lorazepam 1 or 2 mg IV Q3 mins Max 10 mg .

- Dantrolene, a direct-acting muscle relaxant, administered by continuous rapid IV push at a minimum initial dose of 1 mg/kg, repeated until symptoms subside or up to a maximum cumulative dose of 10 mg/kg ( although not better than benzo )

- Dopamine agonists such as, Bromocriptine , Levodopa, and Amantadine ( Didn’t show much benefit )


• Treatment :

• In Refractory cases or cases at risk of aspiration >> RSI

• Use a Nondepolarizing agent (e.g., rocuronium and vecuronium) are required.

• Call ICU People , Give Them This Gift ..

Agranulocytosis

• Clozapine produces agranulocytosis, with 75% of occurrences developing within the first 18 weeks after initiation of therapy, peaking at 3 months.

• No association with Acute Overdose

• Treatment :

• D/C Medication , Problem will go by itself .

Overdose Anyone ?

• In overdose, antipsychotic medications produce signs and symptoms that are exaggerations of the clinical effects.

• Most patients will develop symptoms within a few hours.

• Central nervous system (CNS) depression is universally present, ranging from mild sedation and confusion to coma and loss of brainstem reflexes.

• Airway reflexes can be impaired.

• Respiratory depression can occur after a massive overdose with pro-found CNS depression.

Overdose Anyone ?

• Pupils can be of any size.

• Mild orthostatic hypotension is a common finding from alpha-adrenergic blockade.

• Overdose with low-potency antipsychotics can cause an anticholinergic delirium.

• EPS has been reported with the traditional and atypical antipsychotics.

• Atypical antipsychotic overdose is similar to that of traditional antipsychotics.

• Mimicking opioid

• With the exception of clozapine, seizures rarely occur in overdose.

Overdose Anyone ?

• Treatment :

• Supportive , No specific antidote

• Endotracheal intubation may be required to prevent aspiration or, less often, to support respiration.

• Hypotension is generally mild and responds to IV crystalloids

• Trial of naloxone is warranted.

• Physostigmine and flumazenil are best avoided because of the risk of precipitating seizures.

• Activated charcoal has no proven benefit.

Disposition Based On Presentation

- All The Things That Sounds Serious Goes To >>> ICU

- Patients with a prolonged QT interval, significant ingestions of thioridazine or mesoridazine should have at least 12 hours of cardiac monitoring.

- Patients with less severe signs of toxicity should be observed in the emergency department for a minimum of 4 hours from the time of ingestion, with hospitalization for persistent or worsening signs and symptoms.

- Discharge If Everything is normal , nill acute with ALL STABLE .

Consultation and Referral

• Ideally, all EDs would have psychiatric consultation available at all times.

• In many instances, after initial screening, disposition can be made by referring to a variety of secondary sources for evaluation and treatment.

• Clues that suggest potential violence include hostile behavior, verbal aggressiveness, and statements about violent intent. Such patients need immediate hospitalization.

• Patients with marked disorientation and confusion typically require inpatient medical evaluation for organic components.

• In the absence of medical indications, referral should be made to a psychiatrist or a psychiatric facility with clear discharge instructions, and specific follow-up should be scheduled for any medical, mental health, and/or surgical disorders that were identified.

Disposition In General

• The ultimate disposition of the acutely psychotic patient depends on :

• Underlying cause of the psychosis & Vital Stability .

• Whether the patient is a danger to self or others,

• Presence of social support in the community.

Disposition In General• Hospitalization is indicated for patients who are:

• Experiencing their first psychotic episode.

• Danger to themselves (suicidal) or others (homicidal).

• Debilitated .

• Moderately debilitated but have no social support system within the community

• Have functional or organic psychosis that does not clear .

References

1- Rosen's Emergency Medicine 7th Updated Edition

2- Tintinalli's Emergency Medicine Comprehensive Study Guide 7th Updated Edition

3- American College Of Psychiatrists

4- American Psychiatrist Association

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Date post:	14-Jul-2015
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Emergency Medicine Understanding Of Psychosis

Health & Medicine