Psych Emergencies

Neurological Side Effects of Psychiatric Medications

MedicationAnticholinergic EffectsSedative PropertiesRisk of Extrapyramidal Symptoms
QuetiapineMinimalStrongNone
Haloperidol (Haldol)MinimalMildHigh
OlanzapineMinimalModerateLow
RisperidoneMinimalMildLow
ZiprasidoneMinimalMildLow
  • QT Prolongation – Many antipsychotic medications can extend the QT interval, increasing the likelihood of life-threatening arrhythmias.

Anorexia

Severe risks associated with anorexia nervosa and bulimia include:

  • Electrolyte imbalances (e.g., hypokalemia, hyponatremia)
  • Cardiac arrhythmias with potential for sudden cardiac arrest
  • Esophageal rupture from forceful vomiting
  • Mallory-Weiss tears (bleeding due to esophageal lining damage)
  • Pneumomediastinum (air leakage into the chest cavity)
  • Cardiomegaly due to malnutrition-related heart strain

Overdose: Accidental or Intentional

Key Concept:

  • Cholinergic toxicity = “Wet” (excess secretions)
  • Anticholinergic toxicity = “Dry” (suppressed secretions)
TypeAnticholinergic Cholinergic
ExamplesTrycyclic antidepressantsInsecticides (e.g., sarin gas)
ManifestationsCardiac: Hypotension, prolonged PR/QRS/QT intervals, AV conduction blocks, tachycardia
Neurologic: CNS depression, apnea, delirium, hallucinations, coma, seizures
Other: Mydriasis (dilated pupils), flushed skin, dry membranes, anxiety/psychosis, hyperthermia, urinary retention		Muddles Symptoms:
Miosis(constricted pupils), urination, defecation, diaphoresis, lacrimation, excitation, salivation
TreatmentSodium BicarbonateAtropine

Suicide Risk Stratification Table

High Risk

  • Verbalizes intent to end life
  • Incapable of ensuring personal safety
    • Has a specific plan or engaged in preparatory actions
    • Access to lethal means
    • Experiencing acute psychiatric distress (e.g., severe depression, mania)
    • Facing significant life stressors (e.g., job loss, relationship breakdown, substance relapse)

Intermediate Risk

  • Expresses suicidal thoughts but lacks firm intent
  • Demonstrates ability to stay safe without external intervention
    • Acknowledges reasons to live (e.g., family, personal goals)

Low Risk

  • No current suicidal intent
  • No reported or observed suicidal behaviors
  • No preparatory actions taken
  • Consensus among patient, family, and medical team that safety is not at risk

Respiratory

Pediatric & Pulmonary Essentials

Pediatric Respiratory Considerations

  • Infants breathe primarily through their nose.
  • Avoid excessive neck extension when managing an infant’s airway.
  • Due to proportionally large heads and small torsos, infants are prone to airway obstruction when lying supine.
  • Their relatively large tongue increases the risk of airway blockage.

Signs of Respiratory Distress in Infants

  • Nasal flaring
  • Grunting
  • Head bobbing
  • Retractions
  • Stridor
  • Tachypnea
  • Tachycardia

Pulmonary Embolism (PE)

Risk Factors

  • Prolonged immobility (e.g., long flights, hospitalization)
  • History of DVT or prior PE
  • Recent fracture of a long bone (risk of fat embolism)
  • Recent surgery, particularly pelvic or abdominal procedures
  • Pregnancy, smoking, hypertension, or oral contraceptive use
  • Malignancy

Symptoms

  • Sudden shortness of breath
  • Sharp, pleuritic chest pain (worse with breathing)
  • Rapid breathing and heart rate
  • Sweating and anxiety
  • Possible pleural friction rub

Diagnosis & Treatment

  • Diagnostic tools: D-dimer test, V/Q scan
  • Management: Oxygen, heparin therapy, monitor PT/INR every 4–6 hours

Spontaneous Pneumothorax

Key Features

  • Most common in tall, thin males under 40
  • May be asymptomatic if <40% lung involvement
  • Symptoms: Sudden pleuritic chest pain, diminished breath sounds on the affected side, subcutaneous emphysema, possible tracheal deviation

Treatment

  • Oxygen therapy
  • Small-bore chest tube with water seal or Heimlich valve
  • High Fowler’s positioning

Simple Pneumothorax

Causes

  • Blunt or penetrating trauma (e.g., rib puncturing the lung)
  • Sudden compression of the chest against a closed glottis
  • Rarely, barotrauma

Symptoms

  • Pleuritic chest pain
  • Decreased breath sounds on the affected side
  • Asymmetrical chest wall movement
  • Hamman’s sign (crunching sound with each heartbeat)

Treatment

  • If minimal: Observation
  • Larger cases: Needle thoracostomy or chest tube placement

Tension Pneumothorax

  • Medical emergency—shift of the heart and great vessels to the opposite side, leading to pericardial tamponade
  • A small pneumothorax can rapidly evolve into tension pneumothorax after bag-mask ventilation
  • DO NOT wait for a chest X-ray if symptoms develop

Treatment

  • IMMEDIATE needle thoracostomy

Hemothorax

  • Requires emergent thoracotomy for drainage
  • Autotransfusion indicated for:
    • Large-volume hemothorax
    • Myocardial rupture
    • Major vessel injury

Contraindications for Autotransfusion

  • Blood contaminated by gastrointestinal contents or malignancy

Pulmonary Conditions & Injuries

Pulmonary Edema

Accumulation of fluid in the alveoli and interstitial space impairs gas exchange.
Key sign: frothy, pink sputum

Causes

  • Cardiogenic: Increased left-sided heart pressure
  • Neurogenic: Brain injury-related
  • ARDS: Capillary membrane damage
  • High-Altitude: Rapid ascent beyond 8,000 ft

Symptoms

  • Shortness of breath, tachycardia, tachypnea
  • Anxiety, feeling of “suffocation”
  • S3 gallop

Treatment

  • Position: High Fowler’s
  • Medications: Morphine, nitroglycerin, furosemide
    • Reduce preload, afterload, and intravascular volume

Acute Respiratory Distress Syndrome (ARDS)

Non-cardiogenic lung injury leading to fluid leakage into alveoli, causing collapse.

Risk Factors

  • Sepsis, pneumonia, drowning, trauma, DKA, inhalation injuries, anaphylaxis, overdose

Treatment

  • Mechanical ventilation: Low tidal volumes, pressure-controlled settings

High-Altitude Pulmonary Edema (HAPE)

Develops within 2-4 days after rapid ascent above 8,000 feet.

Symptoms

  • Shortness of breath
  • Pink, frothy sputum
  • Confusion

Treatment

  • Priority: Oxygen via non-rebreather
  • Possible corticosteroids
  • Definitive: Descend to lower altitude

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Bronchitis (“Blue Bloater”)

  • Persistent airway inflammation → chronic cough
  • CO2 retention impairs normal respiratory drive
  • Often overweight

Emphysema (“Pink Puffer”)

  • Alveolar wall destruction → reduced gas exchange
  • Compensatory hyperventilation
  • Classic signs: Barrel chest, pursed-lip breathing, thin/cachectic appearance

Complication: Cor Pulmonale

Right ventricular enlargement due to increased pulmonary vascular resistance.

Symptoms

  • Shortness of breath
  • Jugular vein distention
  • Abdominal discomfort
  • Dependent edema

Pleural Effusion

Excess fluid accumulates between pleural layers.

Causes

  • Most common: Heart failure
  • Other: Pneumonia, malignancy, PE, viral infection, cirrhosis

Symptoms

  • Dyspnea, cough, pleuritic chest pain
  • Decreased breath sounds

Inhalation Injury

Key Signs

  • Hoarseness, stridor, wheezing, cough
  • Carbonaceous sputum (soot in mucus)

Assessment

  • Ask patient to say their name (to check airway patency)

Causes & Effects

  1. Asphyxiation: Carbon monoxide & cyanide poisoning → normal pulse oximetry despite oxygen deprivation
  2. Thermal injury: Burns and swelling in upper airway → risk of obstruction
  3. Smoke poisoning: Toxins damage pulmonary endothelial cells and cilia

Treatment

  • Oxygen therapy (monitor carboxyhemoglobin levels)
  • Racemic epinephrine (for airway swelling)
  • Bronchodilators (for lower airway inflammation)

Pulmonary Contusion

Lung tissue bruising from blunt trauma or barotrauma.

Symptoms

  • Slow-onset respiratory deterioration over hours
  • Dyspnea, cough, hemoptysis

Treatment

  • High-flow humidified oxygen
  • Rapid Sequence Intubation (RSI) if needed
  • Aggressive pulmonary hygiene

Lung Parenchyma Laceration

Penetrating trauma or rib fractures causing lung injury.

Symptoms

  • Hemopneumothorax
  • Hemoptysis
  • Subcutaneous emphysema

Treatment

  • Oxygen therapy
  • Mechanical ventilation if necessary
  • Surgery for severe cases

Tracheobronchial Tree Injury

Severe airway trauma from blunt or penetrating forces.
Mortality: Up to 50% within the first hour OR slow air leakage over 5 days.

Symptoms

  • Airway obstruction (sudden or progressive)
  • Massive hemoptysis
  • Severe subcutaneous emphysema
  • Tension pneumothorax, persistent air leak in chest tube
  • Hamman’s Sign: Crunching sound synchronized with heartbeat

Treatment

  • Airway stabilization
  • High Fowler’s position
  • Chest tube placement
  • Surgical repair if severe

Allergen Timeline

  • Spring: Tree pollen
  • Summer: Grass pollen
  • Fall: Ragweed
  • Year-round: Dust mites, cockroaches

Cystic Fibrosis:

Genetic autosomal recessive disorder impacting multiple exocrine systems

SystemManifestations
RespiratoryChronic rhinosinusitis, recurrent pneumonia, obstructive lung diseases with bronchiectasis
Gastrointestinal (GI)Meconium ileus, distal intestinal obstruction, exocrine pancreatic insufficiency, diabetes mellitus, biliary cirrhosis
Musculoskeletal (MSK)Digital clubbing, osteopenia, pathologic fractures, kyphoscoliosis
ReproductiveMale infertility (95%) > female infertility (20%)

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