ALS and Medical Emergencies in Psychiatry

7/31/2019 ALS and Medical Emergencies in Psychiatry

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ALS and Medical Emergencies in

Psychiatry

John Corish2012


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ALS why do I need to know this?

4-fold increase in risk of acute cardiac eventsin people with schizophrenia

Sudden death

Ventricular arrhythmias

Accelerated atherosclerotic change

Main causes are

Direct pro-arrhythmic effects of antipsychotics Endocrine changes and obesity rates

Sedentary lifestyle, smoking, poor general health


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Basic Life Support (ARC, 2011)

The mnemonic is now D (check for danger before starting)

R (responsiveness is the person rousable or

breathing normally)

S ( send someone for help)

A (airway; clear obstruction, head tilt / jaw thrust)

B

(is the person breathing effectively) C (start chest compressions; 30 then 2 breaths)

D (attach defibrillator ASAP; follow AED prompts)


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Basic Life Support new features

Guidelines now indicate thatunconsciousness and abnormal breathing are

sufficient to warrant CPR.

Attempting to palpate a pulse not

recommended for lay people.

Clinicians should spend


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Advanced Life Support (ARC, 2011)


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ALS Step 1 attach the defibrillator

While attaching defibrillator, follow BLS

protocol of 30 compressions followed by 2

breaths.

Place pads on front and back of left side of

thorax; ensure optimal skin contact.

Ensure sync switch is OFF.


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Types of defibrillators - monophasic

Older, less commonly used. All shocks delivered at 360J.


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Types of defibrillators - biphasic

Widely used in all Hospitals. All shocks delivered at 200J.


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Types of defibrillatorsAEDs

Found in public places, non-acute Hospitals(e.g. Greenwich Hospital)

Shocks delivered automatically and audible

instructions provided know where the

manual over-ride button is.


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ALS Step 2 Assess the rhythm strip

Shockable rhythms ventricular fibrillation (VF)

ventricular tachycardia (VT)

Non-shockable rhythms

sinus rhythm with insufficient output (PEA)

Asystole

Bradycardia (


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Shockable rhythms VF and VT

VF

VT


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ALS Step 3 (shockable) deliver shock

Biphasic immediate 200J shock, thenassess cardiac output, if no pulse detectable

and no indication of respiratory effort or

consciousness continue CPR (30 comp : 2

breaths) for 2 minutes.

Monophasic immediate 360J shock, then

follow the same procedure.

AED will assess rhythm and shock ifappropriate, follow spoken instructions.


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ALS Step 3 (shockable) subsequently

If there is no output, and after 2 minutes ofCPR

Shock again at 200J (biphasic) / 360J (mono) and

assess cardiac output

If no output, give adrenaline 1mg (or 10mcg/kg)then continue CPR for a further 2 minutes

On the next cycle, shock/assess then give one

dose of amiodarone 300mg followed by CPR for a

further 2 minutes Continue to shock/assess/CPR giving 1mg of

adrenaline every 2nd cycle


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ALS Step 3 (non-shockable)

Asystole give adrenaline 1mg immediately followed by CPR

for 2 minutes

Assess after 2 minutes, shock if VF/VT, otherwise

continue CPR for a further 2 minutes, givingadrenaline 1mg at every second cycle (i.e. 0, 4, 8,

mins)

Sinus rhythm (with no output) - PEA

Hs (hypoxia, hypo/hyperthermia,

hypo/hyperkalaemia, hypovolemia)

Ts (tamponade, tension pneumothorax, thrombus,

toxins)


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ALS Step 3 (non-shockable)

Bradycardia (with inadequate output)

Not common

Initially, 1mg atropine every 3 minutes to total of

3mg

If no improvement, most defibrillators will have a

Pacing button/mode that, when engaged, can

transcutaneously pace while the patient is

awaiting PPM insertion


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ALS Step 4 - Post-resuscitation care

Oxygenate to get sats > 95%

Monitor airway patency

Assess for other injuries (spinal, abdominal,

head)

12-lead ECG


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Things that are new

In BLS CPR starts if unconscious and breathing

abnormally, checking pulse not recommended

Chest compressions (30) before first 2 breaths are

given Compressions pause only for breaths/assessment

Compressions still effective even if first aid

provider can not / does not want to give rescue

breaths

AEDs should be used even if staff not trained in

their use


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Things that are new

In ALS Chest compressions continue during defibrillator

charging

All shocks at 200J (biphasic) or 360J (mono)

Atropine is no longer recommended for asystole orPEA routinely

Intubation not prioritised over cardiac status

No precordial thump unless patient develops

VT/VF while monitored


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Other things to keep in mind

take your own pulse Try to stay calm, walk the last 10m as you get to

the arrest

Clearly identify you are in charge and allocate

roles to the others present Send away any non-involved staff, visitors, family

and other patients

Remember that your tone and demeanour will

inevitably reduce or exacerbate the anxiety of theother people present


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Medical Emergencies in Psychiatry

Neuroleptic Malignant Syndrome (NMS)

Serotonin Syndrome (SS)

Status epilepticus

Acute dystonia


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Neuroleptic Malignant Syndrome

Physiology Dopaminergic antagonism resulting in sympathetic

hyperactivity

Possible contribution from elevated NAd and 5HT

levels

Risk factors

Onset of AP, increase in dose, IM route of

administration, cessation of DA agents, high-

potency and typical APs

Pre-existing structural brain lesions

Genetic loading


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Neuroleptic Malignant Syndrome

Diagnosis History, deteriorating mental state, hypertonia and

lead-pipe rigidity, autonomic disregulation

Bloods usually show CK level, WCC and ARF

in severe cases

Treatment

Cease DA-antagonist or re-start DA-agonist,

lorazepam (agitation), correct fluid/electrolyte

imbalances

In HDU, dantrolene (mm relaxant) and

bromocriptine (DA agonist) may be helpful


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Serotonin Syndrome

Physiology Excessive 5HT activity on 5HT1A and 5HT2

receptors; increased NAd activity also likely to be

a factor

Risk factors Serotonergic agents (incl SSRIs. Li, synthetic

opioids, MAOIs, amphetamines, St Johns Wort),

genetic predisposition, drugs with multiple

serotonin-increasing actions often responsible


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Serotonin Syndrome

Diagnosis History, clonus, hypereflexia, autonomic

disregulation, deterioration in mental state with

pronounced agitation, headache

May mimic encephalitis, meningitis, toxinexposure, anticholinergic delirium

Treatment

Mild cease agent, diazepam 10mg q1h and

(debatably) stat dose 6mg cyproheptadine

Severe cease agent, consider early ICU

admission for sedation/intubation


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Status Epilepticus (SE)

Definition continuous seizure activity (+/- convulsions) with

no intervening recovery of consciousness or, for

complex partial seizures, continuous EEG seizure

activity Treatment

Convulsive SE treated with airway/circulatory

support, IV lorazepam/diazepam, IV phenytoin

and, if no resolution, intubation and induced-paralysis with midazolam/propofol


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Acute dystonia

Pathpohysiology Likely due to decreased DA in basal ganglia/motor

cortex with decreased motor inhibition

Risks

Use of any D2- receptor antagonist (although

typical APs much greater problem), Li, SSRIs

Genetic predisposition significant risk factor

Previous problem with other drugs in same class


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Acute dystonia

Features Typically affects 3-5% of all patients on APs and

up to 10% on typical APs

Most commonly in muscles of neck (30%), tongue

(17%), jaw, occular movements

Treatment

Stat dose 2mg IVI benztropine, diazepam 10mg;

symptoms usually resolve in 3-5 mins


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Final thoughts

Attending an arrest is confronting, no matterhow many times youve done it before

You really cant make things worse, so doingsomething (even if youre unsure) will always

be better than doing nothing

If you cant remember anything else, goodCPR with some ventilation will buy you the

10-15mins it generally takes for help to arrive

Documents

ALS and Medical Emergencies in Psychiatry