Psychiatric Emergencies — Viva

Q1: A 40-year-old man with schizophrenia becomes acutely agitated and threatening on the ward. Take me through your stepwise approach to rapid tranquillisation, with named drugs, doses and routes. (2 min)

My sequence is safety first → de-escalation → oral → IM rapid tranquillisation, following NICE NG10 and BAP/NAPICU 2018.^[5][28]

Step 1 — Safety and ABCDE. Scene safety with trained staff in locally defined numbers (NG10 does not specify a universal four-to-five person team). Finger-prick blood glucose early. Exclude an organic cause.

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Step 2 — De-escalation and oral offer. Project BETA: engage, establish collaboration, verbally de-escalate; four objectives (safety, emotional control, avoid restraint, avoid coercion) across 10 domains. Offer oral medication before parenteral. BAP: oral lorazepam may be effective; oral olanzapine, aripiprazole and risperidone are effective (Ib; A); oral haloperidol is effective with a baseline ECG. I do not quote unsourced milligram oral “first-line” boxes as if they were BAP recs.

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Step 3 — IM rapid tranquillisation if de-escalation has failed, oral has been refused and risk is imminent. NICE NG10: IM lorazepam on its own or IM haloperidol combined with IM promethazine. BAP IM monotherapy: IM lorazepam (Ib; A), IM aripiprazole (Ia; A), IM olanzapine (Ia; A) — olanzapine only by itself, not concurrently with IM benzodiazepines (hypotension; wait at least 1 hour). Battaglia: eight fatalities with IM olanzapine; avoid simultaneous CNS depressants. BAP does not recommend IM midazolam (respiratory depression) or IM haloperidol monotherapy (dystonia).

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Step 4 — If no response to IM lorazepam: NG10 1.4.41 / TREC 2007: IM haloperidol 5–10 mg plus IM promethazine up to 50 mg (RR 1.30, NNT 6 at 20 minutes; all 10 dystonias in haldol-alone). ECG before haloperidol. ^{[28] [5] [18]}

Step 5 — Post-IM monitoring. NG10: at least hourly until no further physical-health concerns; every 15 minutes if high-risk features (BNF max exceeded, asleep/sedated, drugs/alcohol, pre-existing physical problem, harm from restraint). BAP medium-level after IM RT: NEWS every 15 minutes for a minimum of 1 hour.

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Q2: A patient on an SSRI is started on tramadol by her GP and presents an hour later with agitation, clonus, hyperreflexia, sweating and a temperature of 39 °C. What is the diagnosis, what criteria do you use, and what is your management? (2 min)

This is serotonin toxicity. Hunter criteria (Dunkley 2003, 2,222 serotonergic overdoses) used clonus (inducible, spontaneous or ocular), agitation, diaphoresis, tremor and hyperreflexia; hypertonicity and maximum temperature over 38 °C were universal in life-threatening cases. Hunter was simpler and more sensitive (84% vs 75%) and specific (97% vs 96%) than Sternbach.

^[10]

Distinguish from NMS: clonus/hyperreflexia and hours-scale onset after a serotonergic agent versus lead-pipe rigidity, slower onset, dopamine antagonist.

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Management:

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1. Stop all serotonergic agents — primary treatment with supportive care (Perry: no evidence-based drug treatments for serotonin syndrome).
2. Benzodiazepines for agitation and neuromuscular excitation; active cooling; IV fluids. Antipyretics do not treat muscle-generated heat.
3. Cyproheptadine 4–8 mg orally in the Graudins five-patient series (three complete resolutions within 2 hours) — adjunct only, oral/NG. I do not quote an unsourced 12 mg loading protocol.
4. Life-threatening: hypertonicity with temperature over 38 °C — ICU, consider intubation and neuromuscular paralysis. ^{[7] [10] [9]}

Q3: Take me through the diagnosis and management of neuroleptic malignant syndrome. (2 min)

NMS is an acute reduction in central dopaminergic tone after D2 blockade or dopamine-agonist withdrawal.^[4]

Gurrera 2011 consensus: recent dopamine-antagonist exposure or dopamine-agonist withdrawal; hyperthermia >38.0 °C (100.4 °F) on at least 2 occasions; rigidity; mental-status alteration; CK at least 4× ULN; sympathetic lability; tachycardia plus tachypnea; negative work-up. Critical values also include BP ≥25% above baseline and BP fluctuation ≥20 mmHg diastolic or ≥25 mmHg systolic within 24 hours. This is not a “five criteria plus six supporting features” score, and the temperature critical value is 38.0 °C, not 38.5 °C.

^[4]

Management: stop the antipsychotic (Guinart: failure to stop OR 4.39 for death); supportive cooling and fluids; dantrolene is the most effective evidence-based drug (Perry); benzodiazepines and dopamine agonists for more severe cases; 2-week neuroleptic washout before considering rechallenge. I do not quote unsourced bromocriptine 2.5–15 mg tds or dantrolene 1 mg/kg protocols as if they came from those papers. ^{[8] [7] [16]}

Q4: A 30-year-old woman is admitted with catatonia — she is mute, postures, and shows waxy flexibility, with three positive Bush-Francis screening features. How do you confirm the diagnosis and what is your treatment? (2 min)

Catatonia is treated in the Bush prospective series with parenteral and/or oral lorazepam for up to 5 days, monitored with the Bush-Francis Catatonia Rating Scale. 16 of 21 (76%) completing a lorazepam trial resolved; a positive parenteral challenge predicted lorazepam response; four lorazepam failures responded promptly to ECT. I do not quote an unsourced “20 mg per day” ceiling as a Bush finding. Avoid first-line antipsychotics if NMS/malignant catatonia is in the differential. ^{[4] [16]}

Q5 (examiner's probe): You mentioned the Mental Health Act. When would you use Section 4 versus Section 5(2), and what is the role of common law in an emergency?

This is statute, not a trial paper.^[28]

Section 4 — emergency admission from the community for assessment, up to 72 hours, one doctor plus AMHP, used when Section 2 (two doctors, 28 days) cannot be completed in time.

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Section 5(2) — doctor's holding power for a patient already an inpatient, 72 hours, to allow full MHA assessment. Section 5(4) nurse holding power 6 hours.

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Common law — immediate life-threatening situation, minimum force, convert to formal MHA/MCA authority as soon as practicable. NG10: seclusion in adults only if detained under the MHA; if a non-detained person is secluded in an emergency, arrange an MHA assessment immediately.

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Q6 (final probe): What is the role of the Mental Healthcare Act 2017 in India, and how does it change the management of a patient who has attempted suicide?

Section 115 MHCA 2017: presumption of mental illness after a suicide attempt and a government duty to provide care — attempted suicide is approached as a health need, not as a criminal matter under the old IPC 309 framing. Other rights-based provisions (advance directive, nominated representative, ban on chained restraint, ECT under anaesthesia/muscle relaxation) are statute teaching. NICE NG225 (UK) additionally: psychosocial assessment at the earliest opportunity, do not delay it until medical treatment is completed, do not use risk tools to predict or to decide discharge, and provide initial aftercare within 48 hours if ongoing safety concerns.^[29]

References13ShowHide

1. [1]Battaglia J. Pharmacological management of acute agitation Drugs, 2005.PMID 15916448
2. [4]Gurrera RJ, Caroff SN, Cohen A, et al. An international consensus study of neuroleptic malignant syndrome diagnostic criteria using the Delphi method J Clin Psychiatry, 2011.PMID 21733489
3. [5]Patel MX, Sethi FN, Barnes TR, et al. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation J Psychopharmacol, 2018.PMID 29882463
4. [7]Perry PJ, Wilborn CA. Serotonin syndrome vs neuroleptic malignant syndrome: a contrast of causes, diagnoses, and management Ann Clin Psychiatry, 2012.PMID 22563571
5. [8]Guinart D, Misawa F, Rubio JM, et al. A systematic review and pooled, patient-level analysis of predictors of mortality in neuroleptic malignant syndrome Acta Psychiatr Scand, 2021.PMID 34358327
6. [9]Graudins A, Stearman A, Chan B. Treatment of the serotonin syndrome with cyproheptadine J Emerg Med, 1998.PMID 9696181
7. [10]Dunkley EJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity QJM, 2003.PMID 12925718
8. [16]Bush G, Fink M, Petrides G, et al. Catatonia. II. Treatment with lorazepam and electroconvulsive therapy Acta Psychiatr Scand, 1996.PMID 8686484
9. [17]Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup West J Emerg Med, 2012.PMID 22461917
10. [18]Huf G, Coutinho ES, Adams CE; TREC Collaborative Group. Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine BMJ, 2007.PMID 17954515
11. [19]TREC Collaborative Group. Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine BMJ, 2003.PMID 14512476
12. [28]National Institute for Health and Care Excellence Violence and aggression: short-term management in mental health, health and community settings NICE guideline NG10, 2015.Source
13. [29]National Institute for Health and Care Excellence Self-harm: assessment, management and preventing recurrence NICE guideline NG225, 2022.Source