ALS and Medical Emergencies in Psychiatry

John Corish 2012

ALS why do I need to know this?

4-fold increase in risk of acute cardiac events in 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

ALS why do I need to know this?

AHPRA / NSWMC policy
All practitioners have an obligation to update their life support skills at least once every 3 years

RANZCP
OSCE (usually station 1) examines medical aspects associated with psychiatric practice Resuscitation stations are revised regularly to reflect the latest ARC Guidelines

Basic Life Support

The mnemonic is now

(ARC, 2011)

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)

Basic Life Support new features

Guidelines now indicate that unconsciousness and abnormal breathing are sufficient to warrant CPR. Attempting to palpate a pulse not recommended for lay people. Clinicians should spend <10 sec trying to find a pulse. Start compressions before giving 2 breaths. Attach defibrillator immediately.

Advanced Life Support

(ARC, 2011)

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.

Types of defibrillators - monophasic

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

Types of defibrillators - biphasic

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

Types of defibrillators AEDs

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.

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 (<60 bpm) with insufficient output

Shockable rhythms VF and VT

VF

VT

ALS Step 3 (shockable) deliver shock

Biphasic immediate 200J shock, then assess 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 if appropriate, follow spoken instructions.

ALS Step 3 (shockable) subsequently

If there is no output, and after 2 minutes of CPR
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

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, giving adrenaline 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)

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

ALS Step 4 - Post-resuscitation care

Oxygenate to get sats > 95% Monitor airway patency

Assess for other injuries (spinal, abdominal, head) 12-lead ECG

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

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 or PEA routinely Intubation not prioritised over cardiac status No precordial thump unless patient develops VT/VF while monitored

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 the other people present

Medical Emergencies in Psychiatry

Neuroleptic Malignant Syndrome (NMS) Serotonin Syndrome (SS)

Status epilepticus
Acute dystonia

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, highpotency and typical APs Pre-existing structural brain lesions Genetic loading

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

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

Serotonin Syndrome
Diagnosis
History, clonus, hypereflexia, autonomic disregulation, deterioration in mental state with pronounced agitation, headache May mimic encephalitis, meningitis, toxin exposure, 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

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 inducedparalysis with midazolam/propofol

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

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

Final thoughts
Attending an arrest is confronting, no matter how many times youve done it before You really cant make things worse, so doing something (even if youre unsure) will always be better than doing nothing If you cant remember anything else, good CPR with some ventilation will buy you the 10-15mins it generally takes for help to arrive