Rosen & Barkin's 5-Minute Emergency Medicine Consult (584 page)

Mental derangement involving hallucinations, delusions, or grossly disorganized behavior resulting in loss of contact with reality

• Complex and poorly understood pathophysiology
  
• An excess in dopaminergic signaling may be a contributing factor
  
• Psychosis ranges from a relatively mild derangement to catatonia
  
• CNS impairment leading to a psychotic presentation may be due to:
  
  • Neurologic disorders
    
  • Metabolic conditions
    
  • Toxins or drug effects
    
  • Infections
    
• Higher risk for underlying psychiatric disorder:
  
  • Hallucinations and illusions incorporated into delusional system
    
  • Late adolescence/early adulthood
    
  • Normal orientation
    
• Higher risk for underlying medical disorder:
  
  • Middle- to late-life presentation
    
  • Acute onset
    
  • History of substance abuse
    
  • No pre-existing psychiatric history
    
  • Absence of a family history of major mental illness
    
  • Presence of pre-existing medical disorders
    
  • Lower socioeconomic level
    
  • Recent memory loss
    
  • Disorientation or distractibility
    
  • Abnormal vital signs
    
  • Visual hallucinations:
    
    • Delirium
      
    • Dementia
      
    • Migraines
      
    • Dopamine agonist therapy (i.e., carbidopa)
      
    • Posterior cerebral infarcts
      
    • Narcolepsy
      

• Neurologic:
  
  • Head trauma
    
  • Space-occupying lesions
    
  • Cerebrovascular accident
    
  • Seizure disorders
    
  • Hydrocephalus
    
• Neuropsychiatric disorders: (Parkinson, Huntington, Alzheimer, Pick, Wilson disease)
  
• Infectious:
  
  • Focal infections in the elderly (UTI, pneumonia)
    
  • HIV
    
  • Neurosyphilis
    
  • Encephalitis
    
  • Lyme disease: Neuroborreliosis
    
  • Parasites:
    
    • Cerebral malaria
      
    • Neurocysticercosis
      
    • Schistosomiasis
      
    • Toxoplasmosis
      
    • Trypanosomiasis
      
• Metabolic:
  
  • Electrolyte imbalance
    
  • Hypoglycemia
    
  • Hypoxia
    
  • Porphyria
    
  • Withdrawal syndromes
    
• Endocrine:
  
  • Thyroid disorders
    
  • Parathyroid disorders
    
  • Diabetes mellitus
    
  • Pituitary abnormalities
    
  • Adrenal abnormalities
    
• End-organ failure:
  
  • Cardiac/respiratory
    
  • Renal
    
  • Hepatic
    
• Nutritional deficiencies:
  
  • Pernicious anemia
    
  • Wernicke–Korsakoff syndrome
    
  • Pellagra
    
  • Pyridoxine deficiency
    
• Autoimmune disorders:
  
  • Systemic lupus erythematosus
    
  • Sarcoidosis
    
  • Myasthenia gravis
    
  • Paraneoplastic syndromes
    
• Demyelinating disease:
  
  • Multiple sclerosis
    
  • Leukodystrophies
    
• Postoperative states:
  
  • Delirium
    
• Intoxicants:
  
  • Alcohol
    
  • Benzodiazepines
    
  • Barbiturates
    
  • Stimulants (cocaine, amphetamines)
    
  • Hallucinogens
    
  • Opiates
    
  • Anticholinergic compounds
    
  • Inhalants
    
  • Cannabis
    
• Toxins:
  
  • Bromide
    
  • Carbon monoxide
    
  • Heavy metals
    
  • Organic phosphates
    
• Medication side effects:
  
  • Corticosteroids
    
  • Anticholinergics
    
  • Sedative–hypnotics
    
• Psychiatric:
  
  • Antidepressants
    
  • Antipsychotics
    
  • Lithium carbonate
    
• Antiparkinsonian drugs
  
• Anticonvulsants
  
• Antibiotics (quinolones, isoniazid)
  
• Antihypertensive agents
  
• Cardiac (digitalis, lidocaine, propranolol, procainamide)
  
• Interferon
  
• Muscle relaxants
  
• Over-the-counter medications:
  
  • Pseudoephedrine
    
  • Antihistamines
    
• Psychiatric:
  
  • Schizophrenia
    
  • Schizoaffective disorder
    
  • Delusional disorder
    
  • Bipolar disorder with psychotic features
    
  • Major depression with psychotic features
    
  • Stress reactions including post-traumatic stress disorder
    
  • Narcolepsy (hallucinations at edge of sleep/wake cycle)
    
  • Postpartum psychosis
    

DIAGNOSIS

• Psychosis characterized by:
  
  • Impaired reality testing
    
  • Inappropriate affect
    
  • Poor impulse control
    
• Focal and diffuse CNS impairment may result in derangements of:
  
  • Perception
    
  • Thought content
    
  • Thought process
    
• Hallucinations:
  
  • Sensory perception that has the compelling sense of reality of a true perception without external stimulation of the relevant sensory organ
    
• Delusions
  
  • Beliefs held with certainty, incorrigibility, and impossibility
    
  • Categorized by type and theme:
    
    • Bizarre or nonbizarre
      
    • Mood congruent or neutral
      
    • Persecutory or grandiose
      
    • Primary or secondary
      
• Thought disorder
  
• Affective symptoms may include mania, depression, or catatonia.
  

• Time course: Acute, episodic, chronic
  
• Collateral from family or outpatient providers
  
• Substance use
  
• Medications and medication adherence
  
• Family history
  
• Associated symptoms: Fever, weight loss, appetite, recent surgery and trauma
  

• Vital signs
  
• Neurologic exam:
  
  • Cognitive exam: Attention and orientation
    
  • Motor exam: Tone, abnormal movements
    

Detailed history and physical exam, including neurologic exam

• Low likelihood of clinically significant findings if there is a past history of psychosis, a benign history, and normal physical exam
  
• 1st line:
  
  • CBC
    
  • Electrolytes including calcium, BUN/creatinine, glucose
    
  • Urine and serum toxicology screen
    
  • Urinalysis
    
  • Liver function tests
    
  • Thyroid function tests
    
  • Vitamin B
    ₁₂
    and folate
    
• 2nd line guided by history and physical findings:
  
  • Ammonia level
    
  • HIV testing
    
  • Fluorescent treponemal antibody absorption (to rule out neurosyphilis; rapid plasmin reagin not sufficient as screen)
    
  • Ceruloplasmin
    
  • Urine heavy metals
    
  • ESR, C-reactive protein, antinuclear antibody
    

• Routine CT or MRI scans are of little benefit
  
• Indications:
  
  • History or exam suggests a neurologic disorder
    
  • 1st-episode psychosis, 50 yr and older
    
• No clear clinically relevant benefit for MRI over CT
  

• EKG with attention to corrected QT interval
  
• Not recommended for routine screening:
  
  • Lumbar puncture
    
  • EEG
    

• Martha Mitchell effect:
  
  • Process by which a clinician mistakes the patient’s perception of real events as delusional
    
• Locked-in syndrome
  
• Periodic paralysis
  
• Conversion disorder
  

TREATMENT

• Ensure safety of patient, bystanders, and medical personnel.
  
• Monitor vital signs, check finger stick.
  

• Safety
  
• Evaluation
  
• Check O
  ₂
  saturation and serum glucose
  
• If uncooperative and dangerous, control behavior
  

• Treat underlying medical illness or substance abuse disorder.
  
• Control psychotic behavior with psychotropic medications
  
• Check for prolonged QT before administering neuroleptic agents
  
• Haloperidol in combination with lorazepam:
  
  • Safe, fast; least disruptive of ongoing medical exam of patient
    
• Atypical neuroleptics:
  
  • Few extrapyramidal side effects
    
  • Olanzapine and ziprasidone can be given IM
    
  • Olanzapine (Zydis) and Risperdal M-tab are available in dissolving wafer preparations.
    
  • Avoid IM lorazepam with IM olanzapine due to risk of respiratory depression.
    

• Haloperidol 2–10 mg IM or IV with lorazepam 0.5–2 mg IM or IV
  

• Neuroleptics:
  
  • Olanzapine: 5–10 mg PO, SL, or IM
    
  • Risperidone: 1–2 mg PO or SL
    
  • Quetiapine: 25–100 mg PO
    
• Benzodiazepines:
  
  • Diazepam: 5–10 mg IV
    

• Increased mortality risk in patients >65 yr on typical and atypical antipsychotics
  
• Start with lower doses (Haloperidol 2 mg IV), Olanzapine 2.5–5 mg PO, SL, or IM).
  
• Use benzodiazepines cautiously, given risk of disinhibition; avoid in delirious patients.
  

Best evidence of safety of antipsychotic use in pregnancy is for 1st-generation (typical) antipsychotics such as haloperidol.

FOLLOW-UP