# Clinical Cases: Psychiatric Emergencies

## Case 1: Neuroleptic Malignant Syndrome

### Patient Demographics
- **Age:** 34 years
- **Sex:** Male
- **Occupation:** Unemployed

### Chief Complaint
"He's burning up and can't move his body right."

### History of Present Illness
The patient is brought to the emergency department by his group home staff with 2 days of progressive symptoms. He was noted to have a fever yesterday morning and appeared increasingly confused and less responsive. Today he has become rigid and is minimally verbal. His temperature at the group home was measured at 104 degrees F. He has a history of schizophrenia and was started on haloperidol 10 mg twice daily approximately 10 days ago after a recent hospitalization for acute psychosis. He had been on risperidone previously but it was discontinued due to inadequate symptom control. His other medications include benztropine 1 mg twice daily.

### Vital Signs
- Temperature: 104.8 degrees F (40.4 degrees C)
- Blood pressure: 168/102 mmHg
- Heart rate: 124 bpm
- Respiratory rate: 24/min
- Oxygen saturation: 94% on room air

### Physical Examination
**General:** Diaphoretic male, minimally responsive, eyes open but not tracking
**HEENT:** Pupils 4 mm bilaterally, reactive; mucous membranes dry
**Cardiovascular:** Tachycardic, regular rhythm, no murmurs
**Pulmonary:** Tachypneic, clear to auscultation
**Abdomen:** Decreased bowel sounds, soft, non-tender
**Neurological:**
- Mental status: Obtunded, does not follow commands, incomprehensible sounds only
- Cranial nerves: Pupils reactive, corneal reflex present
- Motor: Severe generalized rigidity throughout all extremities (lead-pipe rigidity)
- No tremor, no clonus
- Reflexes: Diminished throughout (2+ symmetric)
- No focal deficits identified
**Skin:** Diaphoretic, no rash

### Laboratory Findings
- WBC: 16,800/microL
- Hemoglobin: 15.8 g/dL (hemoconcentration)
- Creatinine: 2.4 mg/dL (baseline unknown)
- BUN: 38 mg/dL
- **Creatine Kinase: 18,450 U/L** (markedly elevated)
- AST: 286 U/L
- ALT: 142 U/L
- Sodium: 148 mEq/L
- Potassium: 5.2 mEq/L
- Lactate: 3.8 mmol/L
- Urinalysis: Brown urine, positive for blood on dipstick, no RBCs on microscopy (consistent with myoglobinuria)

### Additional Studies
- CT Head without contrast: No acute intracranial abnormality
- Lumbar puncture: Normal cell count, protein, glucose (ruling out meningitis)
- Urine drug screen: Negative
- Thyroid function tests: Normal

### Diagnosis
**Neuroleptic Malignant Syndrome (NMS)** secondary to haloperidol
- Rhabdomyolysis with acute kidney injury
- Dehydration

### Management
**Immediate Actions:**
1. Discontinue haloperidol immediately
2. Aggressive IV fluid resuscitation with normal saline (goal urine output >1 mL/kg/hr)
3. Active cooling measures: ice packs to groin and axillae, cooling blanket
4. Foley catheter for urine output monitoring
5. Continuous cardiac monitoring
6. ICU admission

**Specific Pharmacotherapy:**
7. Dantrolene sodium 2 mg/kg IV bolus, then 1 mg/kg IV every 6 hours (direct skeletal muscle relaxant)
8. Bromocriptine 2.5 mg via NG tube every 8 hours (dopamine agonist to restore dopaminergic tone)
9. Lorazepam 2 mg IV every 6 hours PRN for agitation and to reduce rigidity

**Supportive Care:**
10. DVT prophylaxis with sequential compression devices (avoid pharmacologic anticoagulation given rhabdomyolysis)
11. Stress ulcer prophylaxis
12. Serial CK monitoring every 6 hours
13. Renal function monitoring
14. Urine alkalinization if myoglobinuria persists

### Hospital Course
- Temperature normalized by day 3
- CK peaked at 32,000 U/L on day 2, then declined
- Rigidity gradually resolved over 5 days
- Creatinine peaked at 3.1, improved to 1.4 by day 7
- Mental status returned to baseline by day 6
- Dantrolene and bromocriptine tapered over 10 days
- Discharged on day 12 with outpatient psychiatry follow-up
- Antipsychotic rechallenge deferred; if needed in future, will use low-potency atypical agent at lowest dose with close monitoring

### Clinical Pearl
Neuroleptic malignant syndrome is an idiosyncratic reaction to dopamine-blocking agents, most commonly antipsychotics, but also antiemetics like metoclopramide. The four cardinal features are hyperthermia, lead-pipe rigidity, autonomic instability, and altered mental status. Unlike serotonin syndrome (which has rapid onset within hours and is characterized by clonus and hyperreflexia), NMS develops over days and features lead-pipe rigidity with diminished reflexes. The massively elevated CK from sustained muscle rigidity can cause acute kidney injury from myoglobin deposition. Treatment requires immediate discontinuation of the offending agent plus dantrolene (a direct muscle relaxant) and bromocriptine (a dopamine agonist).

### Clinical Image
![NMS ECG Changes](case_01_image.jpg)

**Image Description:** ECG demonstrating sinus tachycardia, a common finding in neuroleptic malignant syndrome reflecting the autonomic instability characteristic of this condition.

**Attribution:** Image from Wikimedia Commons, Category: ECG graphs. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/Category:ECG_graphs

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## Case 2: Acute Suicidal Crisis with High-Risk Features

### Patient Demographics
- **Age:** 42 years
- **Sex:** Female
- **Occupation:** Recently unemployed accountant

### Chief Complaint
"I wrote a note to my kids and was going to take all my pills tonight."

### History of Present Illness
The patient is brought to the emergency department by police after her 16-year-old daughter found a suicide note in her bedroom and called 911. The patient admits she had planned to take an overdose of her amitriptyline and alprazolam tonight after her children went to sleep. She had written goodbye letters to each of her three children. She reports feeling hopeless for the past 3 months since losing her job and her husband leaving her. She has been unable to pay bills and received an eviction notice last week. She states she "can't see any way out" and believes her children would be "better off without me." She denies any previous suicide attempts but endorses passive suicidal ideation over the past several weeks that has intensified to active planning over the past 3 days. She has collected approximately 90 tablets of amitriptyline 50 mg and 60 tablets of alprazolam 1 mg. She denies current alcohol or drug use.

### Psychiatric History
- Major depressive disorder, diagnosed 15 years ago
- Two prior psychiatric hospitalizations for depression (ages 28 and 35), neither involving suicide attempts
- Current medications: Amitriptyline 100 mg at bedtime, alprazolam 1 mg three times daily
- No history of psychosis or mania
- No history of substance use disorder

### Vital Signs
- Temperature: 98.2 degrees F (36.8 degrees C)
- Blood pressure: 142/88 mmHg
- Heart rate: 92 bpm
- Respiratory rate: 16/min
- Oxygen saturation: 99% on room air

### Mental Status Examination
**Appearance:** Disheveled, appears older than stated age, wearing pajamas, tearful
**Behavior:** Cooperative but withdrawn, minimal eye contact, psychomotor retardation
**Speech:** Soft, slow, low volume, decreased spontaneity
**Mood:** "I just want it to end"
**Affect:** Constricted, tearful, congruent with stated mood
**Thought process:** Linear, goal-directed, but ruminative
**Thought content:**
- Active suicidal ideation with specific plan (overdose)
- Lethal means available (90+ TCA tablets, 60+ benzodiazepine tablets)
- Preparatory behaviors (suicide note written, affairs being put in order)
- Hopelessness prominent
- No homicidal ideation
- No delusions or hallucinations
**Cognition:** Alert, oriented x4, attention and concentration impaired
**Insight:** Poor - believes death is the only solution
**Judgment:** Severely impaired

### Suicide Risk Assessment (Columbia-Suicide Severity Rating Scale)
- **Lifetime history:** No prior attempts (lower risk factor)
- **Current ideation:** Active suicidal ideation with specific plan and intent
- **Risk factors:** Major depression, recent major losses (job, marriage, housing), hopelessness, access to lethal means, social isolation
- **Protective factors:** Children (though currently perceived as burden), no prior attempts, no substance use, cooperative with evaluation
- **Overall risk:** HIGH - requires inpatient psychiatric admission

### Management
**Immediate Safety:**
1. 1:1 continuous observation implemented
2. All personal belongings searched and secured
3. Patient placed in safe room (ligature-resistant)
4. Security notified

**Medical Clearance:**
5. ECG: QTc 460 ms (borderline prolonged on TCA)
6. Basic metabolic panel: Within normal limits
7. Urine drug screen: Positive for benzodiazepines (prescribed)
8. Blood alcohol level: Negative
9. Acetaminophen and salicylate levels: Negative
10. Pregnancy test: Negative

**Psychiatric Intervention:**
11. Psychiatric consultation obtained
12. Patient initially refused voluntary admission
13. Involuntary commitment initiated based on:
    - Mental illness (major depressive disorder)
    - Imminent danger to self (active plan, available means, intent)
    - Unable to make informed decisions about care due to severity of depression
14. Emergency commitment petition completed

**Collateral Information:**
15. Daughter interviewed (with patient's consent)
16. Medications secured by police from the home
17. Primary care physician contacted

**Disposition:**
- Admitted to inpatient psychiatric unit on involuntary status
- Medications held pending psychiatric evaluation
- Safety plan to be developed prior to eventual discharge
- Lethal means counseling provided to family (secure all medications, no firearms in home)

### Clinical Pearl
This case demonstrates multiple high-risk features for completed suicide: active ideation with a specific, lethal plan (TCA overdose is highly lethal); available means (stockpiled medications); preparatory behaviors (suicide note, putting affairs in order); hopelessness; recent major losses; and social isolation. The combination of a tricyclic antidepressant and benzodiazepines represents a highly lethal combination. The presence of children, while a protective factor in many cases, is not protective here as the patient perceives herself as a burden. Involuntary commitment is appropriate when a patient with mental illness poses imminent danger to herself and is unable to make informed decisions about psychiatric care.

### Clinical Image
![Columbia Suicide Severity Rating Scale](case_01_image.jpg)

**Image Description:** Diagram illustrating the Columbia-Suicide Severity Rating Scale (C-SSRS) progression from passive suicidal ideation through active ideation without plan, active ideation with plan, to active ideation with plan and intent.

**Attribution:** Image adapted from Columbia Lighthouse Project materials. Public domain educational resource. Source: https://cssrs.columbia.edu/