PsPsychiatric emergencyychiatric emergency

Dagmar SeifertováDagmar Seifertová

Psychiatrické centrum PrahaPsychiatrické centrum Praha

3. lékařská fakulta UK3. lékařská fakulta UK

Causes of psychiatric emergencyCauses of psychiatric emergencyPsychic disorderPsychic disorder

AgitationAgitation

AggressionAggression

Autoaggression - suicidalityAutoaggression - suicidality

Drug useDrug use

IntoxicationIntoxication

Withdrawal syndromeWithdrawal syndrome

Adverse event – treatment relationAdverse event – treatment relation

Neuroleptic malignant syndromeNeuroleptic malignant syndrome

Serotonin syndromeSerotonin syndrome

Acute dystoniaAcute dystonia

Agranulocytosis - clozapineAgranulocytosis - clozapine

AgitationAgitation

Psychic disordersPsychic disorders

Somatic illnessSomatic illness

Psychological crisisPsychological crisis

Procedure: choice of contactProcedure: choice of contact

quick differencial diagnosisquick differencial diagnosis

choice of acute treatmentchoice of acute treatment

Choice of contactChoice of contact

Critic situation – first impression Critic situation – first impression

Be in contactBe in contact

Dialog – brief and clearDialog – brief and clear

Goal – to have basic informationGoal – to have basic information

Leave Leave patient patient to speakto speak

AggresAggressive behavioursive behaviour

Warning singsWarning sings

ProvoProvocationcation – – help refusion help refusion

medication refusionmedication refusion

RiRiskysky – – firstfirst d daysays hospitalisation hospitalisation

involuntary admissioninvoluntary admission

asistence of police asistence of police

First warning – verbal aggressionFirst warning – verbal aggression

History of aggressive behaviourHistory of aggressive behaviour

Aggression – non-specific symptomAggression – non-specific symptom

Personal history of aggressionPersonal history of aggression

Starters of aggressionStarters of aggression

Impulsive behaviourImpulsive behaviour

Gun licence and possession of gunGun licence and possession of gun

Sings of arousal and aggitation Sings of arousal and aggitation

Family history of aggression Family history of aggression

Management of aggression I.Management of aggression I.

Stay calm and do not be cross Stay calm and do not be cross

We can express our distress – usually We can express our distress – usually lower patients aggressionlower patients aggression

Leave patient to speak about what is Leave patient to speak about what is hapenning with himhapenning with him

Aggression escalation – ask for helpAggression escalation – ask for help

Management of aggression II.Management of aggression II.

Never return back to patientNever return back to patientTake off oculars and jewelleryTake off oculars and jewellerySafe exit – open doors, emergency Safe exit – open doors, emergency bellsbells5 person on one aggitated patient 5 person on one aggitated patient Injection use – explainingInjection use – explainingRestriction – frequent controlRestriction – frequent controlIsolation – frequent controlIsolation – frequent control

Etiology of psychiatric agitationEtiology of psychiatric agitation

60% patients – sometime aggressive60% patients – sometime aggressiveAcute stressAcute stressSchizophreniaSchizophreniaManic episode - often womenManic episode - often womenDrug dependencyDrug dependencyPersonality disorderPersonality disorderDemencia and mental retardationDemencia and mental retardation

Other causes of agitationOther causes of agitation

Somatic illness – with feverSomatic illness – with fever

Organic disorder CNS – injury, tumor, Organic disorder CNS – injury, tumor, bleeding, ischemia, infectionbleeding, ischemia, infection

Postoperative statesPostoperative states

HypoglykemiaHypoglykemia

Acute intoxicationAcute intoxication

Drug withdrawalDrug withdrawal

Treatment of acute anxietyTreatment of acute anxiety

Basic sings – panic, agitation, Basic sings – panic, agitation, hyperventilation, sweting, tremorhyperventilation, sweting, tremor

Verbal calming – leave patient speak Verbal calming – leave patient speak

Breathe with patient Breathe with patient

Explain symptomsExplain symptoms

Pharmacological treatmentPharmacological treatment

Pharmacological treatment of Pharmacological treatment of acute anxietyacute anxiety

Benzodiazepine – peroralyBenzodiazepine – peroraly

Diazepame – 10 mgDiazepame – 10 mg

Alprazolame 1 – 2 mgAlprazolame 1 – 2 mg

Lorazepame 1 – 2 mgLorazepame 1 – 2 mg

Clonazepame 1 – 2 mgClonazepame 1 – 2 mg

Longterm treatment – SSRI Longterm treatment – SSRI

Fear from medical procedureFear from medical procedure

Speak about fear- anestesia, pain, Speak about fear- anestesia, pain, handicap,life threatening, deathhandicap,life threatening, death

Brief and concise explanationBrief and concise explanation

Describe desirable and active attitude Describe desirable and active attitude

Possible family helpPossible family help

Possible institution helpPossible institution help

Treatment of acute agitation – Treatment of acute agitation – psychotic patientpsychotic patient

Short goal – minutes to hoursShort goal – minutes to hours

AntipsychoticsAntipsychotics

Combination with benzodiazepinesCombination with benzodiazepines

Mechanical restrictionsMechanical restrictions

IsolationsIsolations

Frequent controlsFrequent controls

Atypical antipsychoticsAtypical antipsychotics

Risperidone -solution 2 mg + BZD Risperidone -solution 2 mg + BZD ( max.8mg)( max.8mg)Ziprasidone – i.m. 10 – 20 mg do max. Ziprasidone – i.m. 10 – 20 mg do max. daily 40 mg ( effect in 15 min)daily 40 mg ( effect in 15 min)Olanzapine Olanzapine i.m. i.m. 10 mg - ( effect in 15 10 mg - ( effect in 15 min )min )AE – risperidone EPSAE – risperidone EPSAE – olanzapine – sedation and AE – olanzapine – sedation and hypotensionhypotension

HaloperidoleHaloperidole

Haloperidole – parenterallyHaloperidole – parenterally

Dose - 5 mg ( max. 10 mg )Dose - 5 mg ( max. 10 mg )

Dosing in short intervals – ( 30 – 60 min)Dosing in short intervals – ( 30 – 60 min)

Combination with BZD – lorazepame 2 -3 mgCombination with BZD – lorazepame 2 -3 mg

clonazepame 1 – 2 mgclonazepame 1 – 2 mg

diazepame 10 – 20 mgdiazepame 10 – 20 mg

Prophylactic use of antiparkinsonicsProphylactic use of antiparkinsonics

– – biperiden, benztropinbiperiden, benztropin

SummarySummary

Agitation is severe complicationAgitation is severe complication

Danger forDanger for pa pattient and suroundingsient and suroundings

EEmpatmpathhic ic attitude from beginingattitude from begining

PrimPrimaryary – verbal calming – verbal calming

Secondary – pharmacological therapySecondary – pharmacological therapy

Mechanical restrictionMechanical restriction

Suicidality – risk factorsSuicidality – risk factors

DepressionDepression Gender - maleGender - male Age : Age : >>45 , or 45 , or <<1919 Suicidal attempt in historySuicidal attempt in history Alcohol and drug abuse Alcohol and drug abuse No social support No social support LonelinessLoneliness Family violence Family violence Somatic illness and painSomatic illness and pain Suicidal planSuicidal plan Psychotic disorder with thought desorganisationPsychotic disorder with thought desorganisation

Evaluation of suicidal planEvaluation of suicidal plan

Decision is serious ?Decision is serious ?

Motivation ?Motivation ?

Patient is mentally ill ?Patient is mentally ill ?

Real problems in life ?Real problems in life ?

Hospitalisation is necessaryHospitalisation is necessary ? ?

Suicidal planSuicidal plan

Preparation – type of suicidePreparation – type of suicide

good by lettergood by letter

Circumstance- be aloneCircumstance- be alone

After suicide – did not look for helpAfter suicide – did not look for help

lasting death wishlasting death wish

sorry for no sucesssorry for no sucess

Neuroleptic malignant syndrome- NMSNeuroleptic malignant syndrome- NMS

Neurological signs– extrapyramidalNeurological signs– extrapyramidal : diffuse muscule rigidity, : diffuse muscule rigidity, symetrical tremor,okulogyric crisis, trismus, dysfagia, symetrical tremor,okulogyric crisis, trismus, dysfagia, opistotonusopistotonus

Autonomic dysfunctionAutonomic dysfunction: fever : fever >> 38 st, tachy 38 st, tachyccardiardia,a, tachypno tachypnoaa,, sudden changes of blood pressuresudden changes of blood pressure, profus, profusee sweatingsweating, , dehydradehydrationtion, in, inccontinenceontinence

ConsciuosnessConsciuosness:: sopor – sopor – ccoma - deliriumoma - delirium

LaboratorLaboratoryy : leukocyt : leukocytosisosis , , creatinphosphocinase creatinphosphocinase multiplemultiple increaseincrease ( ( >> 1,33 mkat ), myoglobinuri 1,33 mkat ), myoglobinuriaa, dif, difffususee EEG EEG abnormalityabnormality

RiRisk factorssk factorsHigherHigher d doseose of of inciincisivesive AP a AP andnd quick dosequick dose increasementincreasement

Higher numberHigher number of of i.m. apli i.m. aplicationcation

PPsychomotor agitsychomotor agitationation

Mechanical restrictionMechanical restriction

DDehydrehydrationation – ( – (humid and tropical climate, central heatinghumid and tropical climate, central heating))

PhysicalPhysical exhaustionexhaustion

ConcommitantConcommitant somatic and infection diseasesomatic and infection disease

PreexistPreexisting ing sub subccllinicinic CNS CNS damage damage

Beginning ofBeginning of alcohol and drug withdrawal alcohol and drug withdrawal

DDopaminergopaminergicic syst system dysfunctionem dysfunction

Childern and teenagersChildern and teenagers

HHormonormonalal dysbalance dysbalance

Course Course a andnd ccompliompliccaationtionss

DevelopmentDevelopment :: during 72 hours during 72 hours

Complications : Complications : myoglobinuric kidney failure myoglobinuric kidney failure

respiration disordersrespiration disorders

cardiovaskular failure - arytmiacardiovaskular failure - arytmia

neuromuscular abnormalitiesneuromuscular abnormalities

Mortality :Mortality : 20 – 30 % ---- now decreased to 10 % 20 – 30 % ---- now decreased to 10 %

Incidence :Incidence : 0,02 – 0,2 – 3,2 % 0,02 – 0,2 – 3,2 %

Differencial diagnosis Differencial diagnosis

- Primary CNS disorder- Primary CNS disorder

- Lethal catatonia- Lethal catatonia

- Somatic illness- Somatic illness

- Malignant hyperthermia / anestézia- Malignant hyperthermia / anestézia

- Serotonin syndrome- Serotonin syndrome

- Heat stroke - - Heat stroke -

Hypothetical etiopatogenessisHypothetical etiopatogenessis

Disturbance of dopaminergic neurotransmition

Dopamin blockade – nigrostriatal – EPS hypotalamic – autonomic symptoms reticular system – stuporDysbalance between dopaminergic and sertonergic system

Dysbalance GABA and acetylcholine

Dysfunction of second messenger in calcium regulation

Dysregulation of sympathic nervous systemu - hyperactivity

Polymorfism of dopaminergic and serotonergic receptors

Pharmacological variablesPharmacological variables

Causes of NMS ( from case reports)Causes of NMS ( from case reports) incisive typical antipsychotics - haloperidole incisive typical antipsychotics - haloperidole depotní APdepotní AP

combination : AP + antiparkinsonics (25 %)combination : AP + antiparkinsonics (25 %) AP + lithiumAP + lithium AP + antidepressants ( SSRI )AP + antidepressants ( SSRI ) sudden withdrawl of antiparkinsonics sudden withdrawl of antiparkinsonics atypical antipsychotics atypical antipsychotics

NMS treatmentNMS treatment1. 1. Withdrawal Withdrawal : antipsychotics + lithiem + anticholinergics: antipsychotics + lithiem + anticholinergics2. Symptomatic therapy2. Symptomatic therapy dantrolene – muscule relaxantdantrolene – muscule relaxant 1 mg – 10 mg / kg (50 mg i.v. 4 x daily)1 mg – 10 mg / kg (50 mg i.v. 4 x daily) bromocriptine - direct dopamine receptor agonistbromocriptine - direct dopamine receptor agonist 7 – 60 mg daily7 – 60 mg daily amantadine - nondirect dopamine receptor agonistamantadine - nondirect dopamine receptor agonist 200 – 400 mg daily200 – 400 mg daily levodopa - dopamine precursorelevodopa - dopamine precursore 2,5 – 5 g daily2,5 – 5 g daily lisuride - dopamin receptor agonistlisuride - dopamin receptor agonist 0,25 – 4 mg daily 0,25 – 4 mg daily elektroconvulzive therapyelektroconvulzive therapy BZD - lorazepame - 30 mg dailyBZD - lorazepame - 30 mg daily

Serotonin syndromeSerotonin syndrome

Psychic symptoms:Psychic symptoms: confusion , aggitation,hypomaniaconfusion , aggitation,hypomania

Neuromuscular symptoms :Neuromuscular symptoms : hyperreflexia,myoclonus,parestezia,hyperreflexia,myoclonus,parestezia, tremor,ataxia,movement discoordination,rigiditytremor,ataxia,movement discoordination,rigidity

Autonomic symptoms :Autonomic symptoms : fever, swetting ,diarrhoea,tachycardia, flu like singsfever, swetting ,diarrhoea,tachycardia, flu like sings

Pharmacological riskPharmacological risk

Dramatic increase of serotonergic transmitionDramatic increase of serotonergic transmition

1) Increase serotonine ( tryptofan) synthesis1) Increase serotonine ( tryptofan) synthesis2) Serotonine release to synaptic cleft2) Serotonine release to synaptic cleft (amfetamins )(amfetamins )3) Blocade reuptake ( SSRI,SNRI,TCA)3) Blocade reuptake ( SSRI,SNRI,TCA)4) Inhibition of metabolism ( IMAO, RIMA )4) Inhibition of metabolism ( IMAO, RIMA )5) Stimulation of seroton receptors ( agonists)5) Stimulation of seroton receptors ( agonists)6) Hypersenzitivity postsynaptic receptors( lithiem)6) Hypersenzitivity postsynaptic receptors( lithiem)7) Decrease of dopaminergic activity7) Decrease of dopaminergic activity

Risk factorsRisk factors

Alteration of serotonergic system –Alteration of serotonergic system –decreased monoaminoxydasis activitydecreased monoaminoxydasis activity

Chronic somatic illneses – hepatal, lungs, Chronic somatic illneses – hepatal, lungs, cardiovascular,hypertension,hyperlipidemiacardiovascular,hypertension,hyperlipidemia

Alcohol and drug abuseAlcohol and drug abuse

Combination : SSRI + IMAO, RIMA, SNRI, Combination : SSRI + IMAO, RIMA, SNRI, moodstabilizers, TCA, APP, třezalka, moodstabilizers, TCA, APP, třezalka, metamaphetamine, erytromycin, linezolidmetamaphetamine, erytromycin, linezolid

Treatment of serotonin Treatment of serotonin syndromesyndrome

1. Withdrawal of serotonergic drugs1. Withdrawal of serotonergic drugs

2. Symptomatic treatment2. Symptomatic treatment

BZD – lorazepame i.v. 1 – 2 mg,or other BZD – lorazepame i.v. 1 – 2 mg,or other

Propranolol – 1 – 3 mg Propranolol – 1 – 3 mg

Cyproheptadine 4 mg po 4 hod Cyproheptadine 4 mg po 4 hod

( antagonist 5- HT)( antagonist 5- HT)

Acute dystonia- clinical singsAcute dystonia- clinical sings

Acute treatment complication – Acute treatment complication – antipsychoticsantipsychoticsAbnormal head and neck postureAbnormal head and neck postureSpasmus of masticatory musculesSpasmus of masticatory musculesSwallowing disturbanceSwallowing disturbanceOculogyric crisisOculogyric crisisTongue hypertonia and protrusion Tongue hypertonia and protrusion Abnormal extremities postureAbnormal extremities postureCould be painfullCould be painfull

Acute dystonie - treatmentAcute dystonie - treatment

anticholinergic antiparkinsonicsanticholinergic antiparkinsonics

Mild sings - per osMild sings - per os

Severe sings -parenterally Severe sings -parenterally

Biperidene 2,5 – 5 mgBiperidene 2,5 – 5 mg

Benzatropine – 2 – 6 mg denněBenzatropine – 2 – 6 mg denně

Catatonic spectrum Catatonic spectrum

Catatonic schizophreniaCatatonic schizophrenia

Affective disorder – severe depression ( melancholy)Affective disorder – severe depression ( melancholy)

Psychogenic stuporPsychogenic stupor

Neuroleptic malignant syndromeNeuroleptic malignant syndrome

Serotonin syndromeSerotonin syndrome

Somatic and neurological disorderSomatic and neurological disorder

AgranulocAgranulocytosis - clozapineytosis - clozapine

Risk – first 18 weeks of treatment Risk – first 18 weeks of treatment ( 75%)( 75%)

Blood account – Blood account –

weekly – first 18 weeksweekly – first 18 weeks

monthly – first yearmonthly – first year

quarterly – maintenance treatmentquarterly – maintenance treatment

risky - virosis risky - virosis

Witdrawal syndrome and Witdrawal syndrome and intoxicationintoxication

Alcohol – delirium tremensAlcohol – delirium tremens

Drugs – different according Drugs – different according pharmacologypharmacology

Antipsychotics – EPS, flu like symptomAntipsychotics – EPS, flu like symptom

Antidepressants – serotonin syndrome, Antidepressants – serotonin syndrome, flu like symptom flu like symptom

Benzodiazepines – grand malBenzodiazepines – grand mal