Overview of psychiatric emergencies

Last updated: June 29, 2023

Summary

This article gives an overview of the most common psychiatric emergencies and how to treat them.

Overview

Overview of psychiatric emergencies
Condition	Risk factors/pathogenesis	Clinical features	Diagnostics	Management
Suicidal behavior	Risk factors for suicidal behavior include: Previous suicide attempt (most important risk factor) Psychiatric conditions Schizophrenia Psychosis Mood disorders (especially major depressive disorder and bipolar disorder) Alcohol or substance use disorder Eating disorders Social factors (e.g., unemployment, low socioeconomic status) Personal factors (male sex, possession of firearms)	Clinical features of the underlying condition	Psychiatric evaluation, involving the direct exploration of: Suicidal ideation Concrete intent/plans Potential underlying conditions Previous suicide attempts	Acute management Imminent risk: hospitalization (if necessary, against the patient's will) Elevated risk Involvement of family Measures to increase patient's social contacts and interaction with medical professionals Long-term management Treatment of underlying psychiatric disorders (e.g., with mood stabilizers, antidepressants) Counseling: providing assistance in improving the patient's social circumstances, as well as development of problem-solving and coping skills
Neuroleptic malignant syndrome	Central D2 receptor blockade in the nigrostriatal pathway and hypothalamus after intake of: Antipsychotic drugs (high-potency FGAs > SGAs) Agents that affect the CNS (e.g., carbamazepine, lithium) Certain antiemetics (e.g., metoclopramide, promethazine) Genetic predisposition	Movement impairment: muscle rigidity (lead-pipe rigidity), akinesia, tremor Autonomic instability Hyperthermia, diaphoresis Cardiovascular instability Tachypnea Altered mental status: reduced vigilance, stupor	↑↑ Creatine kinase Leukocytosis Metabolic acidosis Myoglobinuria	Discontinuation Pharmacotherapy Dantrolene Alternatives: bromocriptine, apomorphine, or amantadine Benzodiazepines
Lithium toxicity	Elevated lithium concentrations as a result of: Overdose (e.g., due to increased dosage) Renal impairment Low effective circulating volume (e.g., due to dehydration, loop diuretic use) Concomitant medication use that increases renal absorption of lithium (e.g., NSAIDs, ACE inhibitors)	Gastrointestinal: nausea, vomiting, diarrhea Neuromuscular Ataxia, slurred speech, nystagmus Fasciculations, hyperreflexia Coarse tremors, seizures Altered mental status: delirium, confusion, somnolence Acute renal failure	Blood work: lithium serum levels > 1.5 mEq/L	Discontinuation Hydration with isotonic fluid Severe lithium toxicity: hemodialysis, ventilatory support if required
Lithium toxicity			Clinical diagnosis: patient history and clinical features
Malignant catatonia	Associated with neuropsychiatric conditions, especially schizophrenia Thought to be the result of neurotransmitter dysregulation	Autonomic dysregulation Fever, sweating Cardiovascular instability, tachypnea Movement impairment: rigidity Altered mental status: delirium		Discontinuation of dopamine blocking drugs Benzodiazepines (intravenous or sublingual lorazepam) ECT
Serotonin syndrome	Ingestion of serotonergic agents that increase the activity of serotonin receptors, including: Psychiatric drugs (e.g., MAOIs, SSRIs, SNRIs) Other drugs (e.g., tramadol, ondansetron, linezolid) Increased risk under the following conditions: Concurrent use of two or more serotonergic drugs Switching from one serotonergic drug to another without tapering	Neuromuscular excitability Hypertonia, myoclonus Hyperreflexia, tremor, seizure Hyperthermia Autonomic dysfunction Diaphoresis, mydriasis Cardiovascular instability Gastrointestinal upset Altered mental status: delirium, psychomotor agitation		Discontinuation Supportive care: cyproheptadine, antihypertensives, fluid replacement, benzodiazepines
Delirium tremens	Alcohol withdrawal in individuals with chronic alcohol use	Altered mental status Visual and tactile hallucinations Impaired consciousness and disorientation, anxiety, disorganized thinking Increased suggestibility Psychomotor agitation Fidgeting, restlessness, emotional lability Reversal of the sleep-wake cycle Insomnia Autonomic instability: tachycardia, hypertension, nausea Additional symptoms in delirium tremens: Alcohol withdrawal seizures Rest and intention tremor (first high frequency, then low frequency)		First-line: benzodiazepines Shorter or intermediate-acting (e.g., oxazepam, lorazepam): Consider in patients with a slow metabolism (e.g., the elderly, those with liver failure) Longer acting (e.g., chlordiazepoxide, diazepam): preferred in all other patients Second-line: anticonvulsants (in case of contraindications for benzodiazepines)
Delirium	Pediatric, elderly (> 65 years), and hospitalized patients are particularly susceptible Most commonly associated with metabolic conditions, such as electrolyte abnormalities, thyroid disturbances Other precipitating factors include: Infections (most commonly UTIs, pneumonia) Trauma, CNS pathologies, hypoxia, acute cardiovascular disease Drugs and toxins (e.g., anticholinergics, sedatives, opioids) Alcohol and illicit substance intoxication/withdrawal Ongoing symptoms (e.g., dehydration, urinary retention)			Treatment of the underlying condition (e.g., discontinuation of precipitating medication, antibiotic treatment of infection) Maintain adequate hydration Reduce confusion (e.g., reorientation to time, place, and person)
Acute dystonia	Inhibition of nigrostriatal dopaminergic pathways caused by antagonism at D2 receptors after antipsychotic intake	Movement impairment Painful and lasting muscle spasms and stiffness Torticollis Oculogyric crisis In severe cases: laryngospasm		First-line: benztropine Alternatives: diphenhydramine, benzodiazepines In case of laryngospasm: intubation
Tyramine-induced hypertensive crisis	Ingestion of tyramine-rich foods, including aged smoked/cured meats and alcoholic beverages (especially beer and red wine) Tyramine stimulates the sympathetic nervous system by releasing other neurotransmitters, such as noradrenaline, from vesicles into the synaptic cleft.	Hypertensive crisis (see “Clinical features of hypertensive crises” for details)		Usually self-limiting, depending on the amount of ingested tyramine Rapid blood pressure reduction is contraindicated
Tricyclic antidepressant toxicity	Ingestion of tricyclic antidepressants which cause various effects, including: Muscarinic ACh receptor inhibition Cardiac fast sodium channel inhibition GABA_A inhibition	Anticholinergic effects Hyperpyrexia, flushed and dry skin, thirst, mydriasis See “Anticholinergic syndrome.” Cardiotoxic effects: prolonged QTc, arrhythmias Neurotoxicity: seizures, coma, respiratory depression		Supportive treatment, e.g., securing airways, oxygenation Activated charcoal Sodium bicarbonate for treatment and prevention of cardiac arrhythmia: monitor with ECG
Tricyclic antidepressant toxicity			ECG: prolonged QTc and QRS

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