Today will be our second (and last) review quiz for the emergency psychiatry theme and our last lesson during this section. Take a few minutes and check your retention.
1) Signs and symptoms of alcohol withdrawal are sometimes categorized as "uncomplicated" and "complicated". Which of the following "complicated" symptoms are at highest risk of occurring between 2-4 days after the last drink?
a) Seizures
b) Delirium tremens
c) Alcoholic hallucinosis
d) Paroxysmal sweats
2) Both methadone and buprenorphine are effective in treating opioid withdrawal symptoms and decreasing abuse of opioids. Which of the following is true of buprenorphine but not of methadone?
a) Can cause QTc prolongation, thus a screening EKG is indicated
b) Long-acting opioid receptor agonist
c) It must be started when the patient is already in withdrawal, or else it will trigger withdrawal symptoms.
d) Associated with increased mortality during the titration phase.
3) 30 yo patient presents to the emergency room after a suspected overdose. Signs/symptoms include disorientation, agitation, visual hallucinations, blurry vision, flushed dry skin, tachycardia, and hypertension. What medication could have caused these symptoms?
a) Donepezil
b) Escitalopram
c) Alprazolam
d) Amitriptyline
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ANSWERS
Question 1:
From day #86
Answer: b
The risk of delirium tremens is at highest risk 48-96 hours (2-4 days) after last drink.
Explanation:
Complicated Withdrawal
Seizure: highest risk 12-48 hours after last drink, however may occur earlier or later. Recommend ruling out organic disease or idiopathic epilepsy during first seizure during medically assisted withdrawal. Treatment of withdrawal with longer-acting benzodiazepine (such as diazepam) significantly reduces risk of seizures.
Alcoholic hallucinosis: highest risk 12-24 hours after last drink and typically resolves within 48 hours. Typically visual and tactile hallucinations with preserved attention and orientation (contrast with DTs).
Delirium tremens (DTs): Also known as alcohol withdrawal delirium. Highest risk 48-96 hours (2-4 days) after last drink. Can last 5 or more days. Symptoms include disorientation, vivid hallucinations, marked tremor, and autonomic instability. Develops in 5% of withdrawal cases and associated with increased mortality (10-20% if untreated). This is a medical emergency and requires transfer to a general medical or ICU setting.
Question 2:
From day #87
Answer: c
Buprenorphine must be started when the patient is already in withdrawal, or else it will trigger withdrawal symptoms.
Explanation:
Both methadone and buprenorphine are effective in treating withdrawal symptoms and decreasing abuse of opioids. Recent systematic reviews find there is no significant evidence to support one over the other 1, 2. The decision for which agent to use is based on individual factors, particularly patient preference, and their long-term plans for maintenance treatment. *Maintenance treatment will be discussed during our substance use section (coming soon)*
Methadone
Long-acting opioid receptor agonist.
Consider for patients with plan to discharge to methadone clinic, as use is restricted to federally licensed substance abuse treatment programs.
Significantly reduces morbidity and mortality in opioid-dependent persons, however is associated with increased mortality during the titration phase.
Can cause QTc prolongation, thus a screening EKG is indicated.
Compared to buprenorphine, plasma levels are more affected by drugs that inhibit/induce CYP450 enzymes such as anticonvulsants, SSRIs, HIV meds, antibiotics, etc.
Compared to low-dose buprenorphine, it is associated with greater retention in outpatient maintenance treatment.
Compared to buprenorphine, there is a greater risk of diversion.
“Gold standard” treatment in pregnant opioid-dependent women.
For specific dosing protocols see UpToDate.
Buprenorphine
Partial opioid receptor agonist. High affinity to opioid receptors.
More readily available since it can be prescribed from regular clinics as long as providers are trained.
Sublingual preparation (Suboxone) combines buprenorphine and naloxone (opioid antagonist). Naloxone is activated if the medication is crushed in an attempt in inject intravenously. This prevents intoxication in this way.
Unlike methadone, there is no association with increased mortality during titration. Also its effects reach a plateau and make overdose unlikely.
Less severe neonatal withdrawal symptoms when used in pregnancy.
It must be started when the patient is already in withdrawal, or else it will trigger withdrawal symptoms. Make sure it has been at least 12 hours since the last opioid use and they are experiencing definite symptoms. The first dose is typically given once COWS reach a score of 8-10.
For specific dosing protocols see UpToDate.
Question 3:
From day #88
Answer: d
The described symptoms are consistent with an anticholinergic toxidrome, thus the answer is amitriptyline.
Explanation:
Anticholinergic
Anticholinergic drugs = compounds that block the action of acetylcholine.
Causes: "pure" anticholinergics include scopolamine, benztropine, trihexyphenidyl, oxybutynin, and plant-based (Jimson weed, angel's trumpet). A number of other medications have anticholinergic properties including antihistamines, atypical and low-potency antipsychotics, tricyclic antidepressants (TCAs), and cyclobenzaprine.
Signs/Symptoms: symptoms can be remembered by the popular mnemonic -> “blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone.” This refers to pupillary dilation and impaired lens accommodation, agitated delirium (can include hallucinations, stereotypic picking behaviors, dysarthric mumbling), flushing, hyperthermia, dry mucosa and skin, gastrointestinal and bladder paralysis, and tachycardia/hypertension. 3 Keep in mind that mixed toxidromes are common if due to antihistamines, antipsychotics, or TCAs.
↑activity/rigidity, ↑HR/BP, ↑Temp, ↑Pupil Size, ~ RR, ↓Bowel Sounds, ↓Sweat.
Treatment: supportive care including activated charcoal (within 1-2 hours of ingestion), IV fluids, and external cooling. Benzodiazepines can be used for treatment of agitation and seizures. Physostigmine (reversible cholinesterase inhibitor) can be given in severe cases with expert guidance.
CONCLUSION
Nice work. You have now finished the emergency psychiatry theme. If you want to see all of the weekly quizzes you can see them here. Next theme we will cover content related to OCD and other impulse control disorders.
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