Psychiatric emergencies

Delirium Tremens
Clinical features
1. Marked tremors
2. Clouding of consciousness
3. Vivid hallucinations/illusions of any sensory modality
4. Signs of autonomic hyperactivity; increased heart rate, blood pressure,

Dr Sayuri Perera and respiratory rate

Usually is seen approximately 3 to 5 days after a patient’s last ingestion of

ethanol
The mortality rate ranges from 5% to 15 %
Risk factors:
 A long history of severe dependence
 Past history of DT, withdrawal seizures
 Old age
 Multiple medical co-morbidities

Managing a patient with aggressive behaviour

Management:
-Early recognition and transfer to a medical ward where i.v.
benzodiazepines (lorazepam/diazepam) can be given
-Parenteral thiamine and other nutritional support
-Managing medical conditions
 Extra-pyramidal side effects

After administering parenteral medications, it is important to monitor the

patient
 BP
 PR
 Temperature
 Respiratory rate
 Every 10 minutes during the first hour and every half an hour until the patient
is ambulatory
 If the patient is still disturbed, should observe for features of respiratory
depression, hypotension, pyrexia and oversedation

Mx of acute dystonic reactions Mx of Pseudo-Parkinsonism

Anticholinergic: IM benztropine 1-2 mgs

Promethazine IM 25 mgs
Reduce the antipsychotic dose
Change to an antipsychotic with lower propensity for pseudoparkinsonism
Patient may not be able to swallow
Prescribe an anticholinergic medication for short-term
Response to IV administration will be seen within 5 minutes
Response to IM administration takes around 20 minutes

Mx of akathisia Mx of tardive dyskinesia

Change to an antipsychotic medication with lower propensity for akathisia

Stop anticholinergics if the patient is already on
Reduce dose of antipsychotic
Propranolol 30–80 mg/day (evidence poor)
Change to an antipsychotic medication with lower propensity for tardive
dyskinesia
Clonazepam (low dose)
Clozapine is the antipsychotic most likely to be associated with resolution
Risk of violence and suicide is higher in patients experiencing akathisia Tetrabenazine
 Neuroleptic Malignant Syndrome (NMS) Management

Features: In the psychiatric unit:

 Withdraw antipsychotics, monitor temperature, pulse, blood pressure
1. Fever
 Consider benzodiazepines if not already prescribed
2. Diaphoresis (sweating)
In the medical/A&E unit:
3. Rigidity, confusion, fluctuating consciousness
 Rehydration, bromocriptine + dantrolene, sedation with benzodiazepines,
4. Autonomic instability (Fluctuating blood pressure, tachycardia) artificial ventilation if required
5. Elevated creatinine kinase, leukocytosis, altered liver function tests  Consider ECT for treatment of psychosis

Clozapine induced neutropaenia/ agranulocytosis Lithium toxicity

WBC/DC
monitoring

Green Amber Red

(WBC – 3.0-
(WBC>3.5*109 and (WBC<3.0*109 and/or
3.5*109 and/or N
N >2.0*109) N <1.5*109)
1.5-2.0)

Sample blood twice
weekly until counts
stabilise or
increase
Stop tx immediately
Sample blood daily until a
green result is achieved.
Monitor for signs of
infection.

Features of lithium toxicity Mx of Li toxicity

Signs and symptoms of mild toxicity: Stop lithium immediately

 Gastrointestinal (GI) including nausea, vomiting, cramping, and sometimes diarrhoea
 Neuromuscular signs such as tremulousness, dystonia, hyperreflexia and ataxia
Consider DDs
Hydrate well
Signs and symptoms of severe toxicity
 Altered mental status Depending on the severity may need medical intervention/ dialysis/ICU
 Muscle fasciculations care
 Stupor
 Seizures Investigations: Urgent lithium level
 Coma • SE
 Hyperreflexia • Serum creatinine/ e GFR
• TFTs
 Cardiovascular collapse
• Other relevant Ixs