Acute psychosis: Difference between revisions
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**'''No history of psychosis''' | **'''No history of psychosis''' | ||
***Haloperidol 0.5mg-5mg + lorazepam 0.25-2mg (PO/IM/IV) | ***Haloperidol 0.5mg-5mg + lorazepam 0.25-2mg (PO/IM/IV) | ||
***Consider adding benztropine 0.5-2mg '''or''' diphenhydramine 25-50mg (PO/IV/IM) | ***Consider adding benztropine 0.5-2mg '''or''' [[diphenhydramine]] 25-50mg (PO/IV/IM) | ||
****reduces dystonia or EPS | ****reduces dystonia or EPS | ||
***Consider risperidone 0.5-2mg PO '''or''' olanzapine 2.5-20mg (PO/IM/SL) '''or''' ziprasidone 10-20mg IM | ***Consider risperidone 0.5-2mg PO '''or''' olanzapine 2.5-20mg (PO/IM/SL) '''or''' ziprasidone 10-20mg IM | ||
Revision as of 05:09, 3 August 2016
Background
- Caused by many psychiatric and medical conditions
- Examples: schizophrenia, mania
Clinical Features
- Agitation
- Restlessness
- Irritability
- Decreased attention
- innappropriate or hostile behaviors
Differential Diagnosis
Altered mental status
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
- Hypertensive Encephalopathy
- Toxins
- TTP / Thrombotic thrombocytopenic purpura
- Alcohol withdrawal
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Wernicke encephalopathy
- Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
- Sepsis
- Osmotic demyelination syndrome (central pontine myelinolysis)
- Limbic encephalitis
Primary CNS disease or trauma
- Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
- Vascular disease
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic encephalitis
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
Evaluation
- Vital signs
- Blood glucose
- signs or symptoms of intoxication or withdrawal
- signs of trauma
- rule out any organic causes or contributors
Management
- Non-pharmacologic
- Verbal de-escalation
- Offer comforting items: blanket, meal, pillow, etc
- Quiet room
- Physical restraints
- should administer medications if restraints used (decreases restraint time)
- Pharmacologic: Goal is to calm patient without oversedation
- No history of psychosis
- Haloperidol 0.5mg-5mg + lorazepam 0.25-2mg (PO/IM/IV)
- Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM)
- reduces dystonia or EPS
- Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg (PO/IM/SL) or ziprasidone 10-20mg IM
- Known or suspected underlying psychotic illness
- Continue treatment with previous antipsychotic or
- PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
- IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
- (PO/IM/IV) Haloperidol 0.5-5mg + lorazepam 0.5-2mg
- No history of psychosis
Disposition
- Depends on underlying cause of psychosis
- Hospitalization for first psychotic episode, suicidal or homicidal, unable to care for self or poor support system
See Also
External Links
References
Brown, H. et al How to stabilize an acutely psychotic patient. Current Psychiatry. Dec 2012. Vol 11. No 12. p10-16
Rosen's Emergency Medicine 7th ed