Psychiatric Emergencies in the Hospital (Kostick, 2/3/2021)

Many thanks to Dr. Talia Kostick for an excellent presentation on Psychiatric Emergencies in the Hospital: etiologies, clinical presentations, and treatments. She also included a bit on medical-decision making capacity and involuntary hospitalization-- issues we confront quite frequently in the hospital.

Dr. Kostick took us through 4 cases of patients we cared for at SSRRH with these Psychiatric Emergencies. If you want to see the recording, it is available here: https://youtu.be/Tr0I22vNuiY

Psychiatric emergency: when a psychiatric condition causes an imminent threat to the life of the patient or the possibility of permanent neurologic or physiologic damage. These include:  

• Serotonin Syndrome
• Catatonia
• NMS 
• Anticholinergic Toxicity
• Suicidal Intent (not covered her)

Serotonin syndrome: potentially fatal drug induced condition, caused by too much serotonin in the synapses in the brain. Patients present with a combination of neuromuscular, autonomic, and mental status symptoms

• s/sx: clonus, tremor, sweating, tachycardia, restlessness, confusion, delirium
• meds common cause: MAOi, Antidepressants (SSRI, SNRI, TCAs), opiates, natural health products. Worse in combination, high dose
• treatment: 
• discontinue any/all serotonergic drugs
• supportive care (esmolol, nitroprusside)
• sedation with benzos
• paralytics and intubation for hyperthermia
• in serious cases serotonin antagonists

Catatonia: displaying 3 or more of 12 psychomotor features (see table)

• usually diagnosed inpatient
• majority in depression, can occur up to 35% of patients with schizophrenia
• s/sx: immobility, mutism, withdrawal and refusal to eat, rigidity, echolalia (see table)
• treatment: benzos! (1-2mg of SL, IV or IM lorazepam--> repeat in 3 hours), also ECT effective
• more likely to respond if bipolar, less likely if schizophrenia

Neuroleptic Malignant Syndrome (NMS): alteration in the autonomic and somatic nervous system caused by decreases in function of the central dopamine system

• 10% mortality (more fatal than serotonin syndrome)
• incidence 0.01-0.2% of all patients treated with antipsychotics
• greatest risk in high dose first generation psychotics (e.g. haldol)
• diagnosis of exclusion: 1) exposed to dopamine antagonist 2) mental status change 3) "lead pipe muscle rigidity", autonomic instability (tachy, tachypnea, hypertension), hyperthermia w/diaphoresis, elevated CK
• tx: stop dopamine antagonist, can add dopamine agonist ( bromocriptine, amantadine, levodopa), decreased noradrenergic activity (with benzos)

Anticholinergic Toxicity: 

• blind as a bat, hot as a desert, mad as a hatter, dry as a bone, red as a beet (see image)
• LOTS of meds with anticholinergic effects: antiemetics, corticosteroids, analgesic, steroids
• Tx: stop the med, provide supportive care, in severe cases (cardiac effects), can administer physostigmine

Capacity Assessment: 4 parts

1) Comprehension: Can patient express an understanding of current medical conditions, risks/benefits of proposed treatments?

2) Expression of a choice: Does the patient have the ability to state and explain their decision?

3) Appreciation: Is the patient able to appreciate the consequences of their decision?

4) Depression/delusions/intoxication: if any of these affecting decisions, do not have capacity