Acute mania and hypomania management

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Target exams

Red flags

• Mania or mixed features with active suicidal intent, psychosis, extreme aggression, or catastrophic risk behaviour — same-day senior review and likely admission
• First mania after mid-life, fever, fluctuating attention, focal neurology, or seizure — intensify organic work-up before locking primary bipolar
• IM olanzapine plus parenteral benzodiazepine — never co-administer (respiratory depression risk)
• Lithium toxicity: coarse tremor, ataxia, confusion, vomiting, dysarthria — stop lithium, check level and renal function urgently
• Valproate in people who can become pregnant without documented pregnancy-prevention counselling — major teratogen hierarchy
• Prolonged prone restraint or unmonitored seclusion — positional asphyxia and sudden-death risk
• Antidepressant continuation or initiation during mania/hypomania or mixed features — polarity-unsafe