Substance Intoxication and Withdrawal - Psychiatry

Snapshot
- A young male is brought into the ED by his friends who say he is not responding to them. The patient seems extremely drowsy and has slurred speech. On physical exam he has pinpoint pupils and his respiratory rate is 4/min.

Snapshot
- A patient presents to the ED with impaired memory, poor concentration and extreme drowsiness. Pupils are not dilated on exam and the patient is minimally responsive. Of greatest concern is the patient's respiratory rate of 5/min.

Snapshot
- A patient with a past medical history of panic attacks and anxiety is brought into the ED by her husband as she has been stuporous and has been minimally responsive and extremely drowsy. The patient's husband mentions that his wife did have a panic attack today.

Snapshot
- A 25-year-old male is brought into the ED by his own volition as he has been unable to sleep for the past 5 nights and is concerned. He says he feels as if he doesn't need to sleep but came in at the request of his friend. He has been studying all night for finals and says he has been, "in the zone," and been unable to stay up all night with no need for sleep.

Snapshot
- A 23-year-old female is brought into the ED by her friends as they are concerned about her behavior. She seems more energetic than usual and this has gone on well past the end of the rave. On exam, you see a young female in neon clothing, consumed with the colors of her outfit, and very affectionate towards you.

Snapshot
- A 21-year-old male is brought into the ED by the police for an altercation. Last night, the patient was at a party and seemed much more active than usual according to his girlfriend. He punched another male at the party in the face claiming that he was hitting on his girlfriend. On exam, you see an agitated young male with dilated pupils, and his pulse is 128/min.

Snapshot
- A 22-year-old college student has been studying for finals but came into the emergency department because of a strange sensation in her chest and a feeling of palpitations. She has been studying every night consuming copious amounts of energy drinks and is unsure what is going on but is afraid that she is, "having a heart attack from all the stress." A segment of the girl's EKG is pointed out to you by the on call cardiologist.

Snapshot
- A patient comes to his primary care physician because he has felt more anxious and irritable lately. He states that he has been very stressed out at work lately and thinks that his symptoms are attributable to the stress. He smokes 1 pack per day, but lately has found himself smoking up to 4 packs per day to ease his stress. Upon further counseling he says he is interested in quitting and wants your help.

Snapshot
- A young man is brought into the ED and has attempted to assault a nurse several times. He is extremely aggressive and becomes enraged when sudden movements or loud sounds are made. The patient is escorted to a dimly lit, quiet exam room where he becomes much calmer. On physical exam, the patient is agitated and has nystagmus. His blood pressure in the ED is 180/100 mmHg.

Snapshot
- A 23-year-old male is brought into the ED by his friends at 1 a.m. They are afraid that he is going to hurt himself. They say that he has "been freaking out" and seeing things that are not there. At one point, he tried to ride a bike off the roof of a house. On exam, you see a young man who appears to be in a panic. His gait is abnormal, he has diffuse tremors and his pupils are dilated.

Snapshot
- A 17-year-old male is brought to his family physician by his parents due to his behavior - increased appeptite, lack of motivation, and paranoia. When interviewing the patient, the physician notes a slowed speech and conjunctival injection.

Snapshot
- A 15-year-old male is brought to the ED for aggressive behavior. This patient has been admitted to the ED many times, last time for abusing bath salts. He comes from a foster home and is largely unsupervised.

Snapshot
- A 69-year-old male presents to the emergency department with sudden, severe onset epigastric pain that began while he was watching television. On physical exam is an unkempt male with pain upon palpation of the epigastric region. Labs are drawn and the patient has an elevated amylase and lipase. The patient is made NPO, an NG tube is placed, and the patient is given IV fluids. The patient is noted to be experiencing hallucinations. On his second hospital day, the patient has a seizure.

Alcohol

	Minor Withdrawal	Alcoholic Hallucinosis	Withdrawal Seizure	Delirium Tremens
Time Since Last Drink	6 hours	12 - 24 hours	48 hours	48 - 96 hours
Symptoms	Trembling Irritability Anxiety Headache Tachycardia Insomnia	Visual, auditory, and in some cases tactile hallucinations	Tonic-clonic seizures	Autonomic instability Disorientation Hallucinations Agitation
Management	Thiamine Folate Multivitamin Dextrose IV Fluids	Benzodiazepines lorazepam diazepam - longer half life midazolam drip though not a preferred initial agent Barbiturates simple single dose that auto-tapers preferred in very ill or highly symptomatic patients to reduce ICU admissions	Benzodiazepine taper Head CT	Suspect in patient with unknown history follwed by DT symptoms 2 days later Benzodiazepine taper

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