Why this matters in emergency medicine: Psychotropic medicines can restore function and prevent relapse, but they can also cause airway compromise, seizures, dysrhythmias, hyperthermia, severe hypotension, delirium and self-harm when misused. An EMT may be the first professional to recognise an adverse drug reaction, intentional overdose, withdrawal syndrome or a medical illness presenting as “psychiatric.” This guide links pharmacology to rapid assessment, safe transport, respectful communication and referral.
Scope and safety: These are learning notes, not a substitute for a prescriber, poison-centre advice, the Uganda Clinical Guidelines, local formularies or an emergency protocol. Never start, stop, combine or rapidly change a psychotropic medicine without the responsible clinician. In a deteriorating patient, use an ABCDE approach, call for senior/medical support early and treat life threats before making a diagnostic label.
Learning outcomes
- Explain how major neurotransmitter systems relate to symptoms and medicine effects.
- Classify antidepressants, antipsychotics, mood stabilisers, anxiolytics, hypnotics and medicines used in substance-related emergencies.
- Recognise serotonin syndrome, neuroleptic malignant syndrome (NMS), acute dystonia, akathisia, tardive dyskinesia, lithium toxicity and severe withdrawal.
- Perform a medication-focused history, risk assessment, monitoring plan and clear handover.
- Support a person with agitation, psychosis, mania, self-harm or overdose without stigma, coercion or unsafe restraint.
1. What is psychopharmacology?
Psychopharmacology is the study of medicines that change mood, thinking, perception, behaviour, sleep, attention or impulse control. Medicines act at synapses by changing neurotransmitter release, receptor activity, reuptake or metabolism. Clinical response is usually slower than the plasma concentration change: sedation may occur after one dose, while antidepressant or antipsychotic benefit often takes days to weeks. This difference prevents premature dose escalation and helps the EMT explain why a patient may still be distressed despite taking treatment.
Emergency rule: A behavioural presentation is a symptom, not a diagnosis. Hypoglycaemia, hypoxia, hypercapnia, head injury, stroke, sepsis, meningitis, intoxication, withdrawal, thyroid disease and medication toxicity can all look like agitation, confusion or psychosis.
Core neurotransmitters and the bedside link
| System | Main functions | Clinical relevance |
|---|---|---|
| GABA | Inhibitory “braking” of the CNS; muscle relaxation and anticonvulsant effect. | Benzodiazepines enhance GABA-A activity; excess causes drowsiness, hypoventilation, ataxia and coma. Withdrawal can cause tremor, anxiety, seizures and delirium. |
| Glutamate | Major excitatory transmitter; learning, memory and arousal. | Excess excitotoxicity is relevant in seizures and injury; NMDA antagonism contributes to ketamine dissociation and analgesia. |
| Dopamine | Movement, reward, attention and salience. | Excess mesolimbic activity is associated with hallucinations/delusions; blockade can cause parkinsonism, dystonia, akathisia and NMS. |
| Serotonin (5-HT) | Mood, anxiety, sleep, appetite, gut motility and temperature regulation. | SSRIs/SNRIs increase signalling; combinations or overdose may produce serotonin syndrome. |
| Noradrenaline | Alertness, arousal, attention, vascular tone and stress response. | SNRIs and some TCAs increase it; toxicity can cause hypertension, tachycardia, agitation and dysrhythmia. |
| Acetylcholine | Memory, attention, autonomic and neuromuscular function. | Anticholinergic effects cause dry mouth, blurred vision, urinary retention, ileus, tachycardia and delirium. |
| Histamine | Wakefulness, appetite and itch. | H1 blockade explains sedation and weight gain with some antipsychotics and antidepressants. |
2. Classification used in emergency care
| Group | Examples | Typical roles | Emergency hazards |
|---|---|---|---|
| Antidepressants | SSRIs: fluoxetine, sertraline, escitalopram; SNRIs: venlafaxine, duloxetine; TCAs: amitriptyline; others: mirtazapine, bupropion, MAOIs. | Depression, anxiety disorders, OCD, PTSD, neuropathic pain (some agents). | Serotonin syndrome, withdrawal, seizures, QT/QRS abnormalities and coma in overdose. |
| Antipsychotics | First generation: haloperidol, chlorpromazine. Second generation: risperidone, olanzapine, quetiapine, aripiprazole, clozapine. | Psychosis, schizophrenia, mania, severe agitation; some bipolar depression. | Acute dystonia, akathisia, NMS, QT prolongation, hypotension, aspiration and metabolic disease. |
| Mood stabilisers | Lithium, valproate, carbamazepine, lamotrigine. | Bipolar mania or maintenance; seizure disorders; selected bipolar depression. | Narrow therapeutic index, renal/hepatic toxicity, blood dyscrasias, teratogenicity and serious rash. |
| Anxiolytics/sedatives | Diazepam, lorazepam, midazolam; buspirone; selected hypnotics. | Severe anxiety, seizures, alcohol withdrawal, procedural sedation. | Respiratory depression, aspiration, paradoxical agitation, falls, dependence and withdrawal. |
| Substance-use medicines | Naloxone, methadone/buprenorphine programmes, acamprosate, naltrexone, thiamine protocols. | Overdose reversal, withdrawal prevention and relapse reduction. | Precipitated withdrawal, respiratory depression, QT prolongation or missed Wernicke prophylaxis. |
3. Safe psychotropic medicine principles
- Confirm the person and the product: name, strength, formulation, route, time of last dose, indication, prescriber and adherence.
- Check the context: new medicine, dose increase, missed doses, recent infection, dehydration, pregnancy, alcohol/recreational drugs, over-the-counter medicines and herbal products.
- Use one change at a time where possible: simultaneous changes make adverse effects and therapeutic response difficult to interpret.
- Do not abruptly stop long-term therapy: withdrawal or relapse can be dangerous; tapering is planned by the treating clinician.
- Monitor physiology, not just behaviour: airway, respiratory rate, oxygen saturation, pulse, blood pressure, temperature, glucose, ECG, level of consciousness and hydration.
- Use the least restrictive safe approach: verbal de-escalation, a calm environment and trained staff precede medication or restraint unless there is immediate life-threatening violence.
4. Antidepressants
Antidepressants are used for depressive disorders and several anxiety-related conditions. They are not “happy pills”: benefit requires a therapeutic trial, adherence and psychological/social support. Early activation, insomnia, nausea or anxiety may occur before mood improves. In a young person or anyone with new suicidal thoughts, arrange urgent review rather than simply increasing the dose.
SSRIs and SNRIs
| Feature | SSRIs | SNRIs |
|---|---|---|
| Examples | Fluoxetine, sertraline, citalopram, escitalopram, paroxetine. | Venlafaxine, duloxetine, desvenlafaxine. |
| Common effects | Nausea, loose stool, headache, insomnia or somnolence, sexual dysfunction. | SSRI effects plus sweating, tremor, increased pulse or blood pressure. |
| Important interactions | Other serotonergic drugs, tramadol, linezolid, MAOIs, some migraine medicines and herbal St John’s wort. | Same serotonergic risk; medicines affecting blood pressure require caution. |
| Withdrawal | Dizziness, “electric shock” sensations, irritability, flu-like symptoms, sleep disturbance. | Often more prominent with short half-life drugs; taper under clinician guidance. |
| EMT priority | Ask about a recent switch or combination; screen for serotonin syndrome, mania, overdose, self-harm and severe hyponatraemia symptoms. | |
Serotonin syndrome — “HOT, WET, SHAKY, FAST”: hyperthermia, diaphoresis, diarrhoea, agitation/confusion, tremor, hyperreflexia/clonus, tachycardia and hypertension. It is a clinical emergency: stop suspected serotonergic agents as directed, begin ABCDE, cool safely, manage seizures/agitation per protocol and arrange urgent medical/poison-centre support.
Tricyclic antidepressants (TCAs)
Amitriptyline, imipramine and related TCAs block reuptake of noradrenaline and serotonin but also block muscarinic, histamine and alpha-1 receptors. This explains their anticholinergic effects, sedation, postural hypotension and high toxicity in overdose. A patient with a possible TCA overdose requires immediate ECG and continuous monitoring; QRS widening, hypotension, ventricular dysrhythmia, seizures or reduced consciousness are red flags. Sodium bicarbonate and advanced management are clinician-led under the local toxicology protocol.
MAOIs and other antidepressants
- MAOIs: dangerous interactions with serotonergic medicines, sympathomimetics and tyramine-rich foods; severe headache, hypertension, hyperthermia or agitation needs urgent care.
- Mirtazapine: sedation and increased appetite are common; overdose is often less cardiotoxic than TCAs but still requires assessment.
- Bupropion: may lower seizure threshold; repeated or modified-release overdose can cause delayed seizures and dysrhythmias.
- Ketamine/esketamine: specialist use only; monitor airway, blood pressure, dissociation and emergence reactions.
5. Antipsychotic medicines
Antipsychotics reduce dopamine signalling to treat hallucinations, delusions, severe thought disorder and mania. They do not replace a search for delirium, intoxication, withdrawal, hypoxia, hypoglycaemia, infection or neurological disease. Second-generation agents may have less movement toxicity for some patients but can cause major metabolic, cardiac and sedation effects.
| Class/agents | Practical strengths | Major adverse effects | EMT observations |
|---|---|---|---|
| First generation: haloperidol, chlorpromazine | Useful for psychosis or severe agitation when prescribed; haloperidol has relatively little anticholinergic sedation. | Dystonia, akathisia, parkinsonism, tardive dyskinesia, NMS, QT prolongation; chlorpromazine can cause marked hypotension. | Check temperature, rigidity, pulse, ECG risk, hydration and co-administered QT-prolonging drugs. |
| Risperidone, paliperidone | Psychosis and maintenance; long-acting formulations support adherence. | Extrapyramidal symptoms, raised prolactin, orthostasis and QT risk. | Ask about rigidity, tremor, menstrual/sexual effects and recent depot injection. |
| Olanzapine, quetiapine | Psychosis and bipolar illness; quetiapine is sedating. | Weight gain, diabetes, dyslipidaemia, postural hypotension, sedation; QT risk. | Protect airway when drowsy; check glucose and falls risk. |
| Aripiprazole | Partial dopamine agonist; often less sedating and less metabolic effect. | Akathisia, insomnia, nausea and impulse-control problems. | Restlessness may be akathisia, not worsening psychosis—ask before giving more sedative. |
| Clozapine | Specialist treatment for treatment-resistant schizophrenia and reduction of recurrent suicidal behaviour in selected patients. | Neutropenia/agranulocytosis, myocarditis, seizures, severe constipation/ileus, hypersalivation, metabolic effects and sedation. | Fever, sore throat, infection, chest pain, breathlessness, abdominal distension or collapse is urgent; never interrupt monitoring casually. |
Extrapyramidal syndromes
| Syndrome | Typical timing/findings | Immediate EMT response |
|---|---|---|
| Acute dystonia | Hours–days: painful neck spasm, jaw/tongue protrusion, oculogyric crisis, dysphagia or laryngospasm. | Airway first; call for urgent treatment with an anticholinergic/antihistamine per protocol. Do not assume seizure or “bad behaviour.” |
| Akathisia | Days–weeks: inner restlessness, pacing, inability to sit still, anxiety and sometimes suicidal distress. | Ask directly about restlessness; notify prescriber. More antipsychotic may worsen it. |
| Parkinsonism | Weeks–months: bradykinesia, rigidity, resting tremor, shuffling gait. | Falls precautions and medication review; do not stop abruptly without a plan. |
| Tardive dyskinesia | Months–years: repetitive lip smacking, tongue movements, chewing or choreiform limb movements. | Document and refer; avoid dismissing it as anxiety. Long-term specialist treatment may be required. |
| NMS | Rapid rigidity, hyperthermia, altered consciousness, autonomic instability and raised CK after dopamine blockade or withdrawal of dopaminergic drugs. | Life-threatening emergency: stop suspected trigger under medical direction, ABCDE, active cooling, IV access/fluids and urgent critical-care referral. |
NMS versus serotonin syndrome: NMS usually develops over days with “lead-pipe” rigidity, bradyreflexia and a dopamine-blocking exposure; serotonin syndrome often develops rapidly after serotonergic exposure with clonus, hyperreflexia, tremor, diarrhoea and diaphoresis. There can be overlap—treat the patient’s physiology and seek specialist help rather than relying on a single sign.
6. Mood stabilisers
Mood stabilisers reduce recurrence of mania and depression in bipolar disorder and may be used for seizure disorders. They require adherence, laboratory monitoring and a clear plan for pregnancy, renal/hepatic disease and drug interactions. WHO guidance supports lithium, valproate or carbamazepine for bipolar mania where appropriate; lithium should be initiated only where close clinical and laboratory monitoring is available. Maintenance choices are individualised and should be continued long enough to prevent relapse unless toxicity or another contraindication occurs.
Lithium
| Topic | Teaching and emergency significance |
|---|---|
| How it is used | Acute mania and bipolar maintenance; a narrow therapeutic index means the effective and toxic concentrations are close. |
| Monitoring | Serum level at the correct time after dosing, renal function, electrolytes, thyroid function, weight, hydration and pregnancy status where relevant. |
| Why levels rise | Dehydration, vomiting/diarrhoea, fever, low-salt diet, acute kidney injury and interacting medicines such as NSAIDs, ACE inhibitors/ARBs and thiazide diuretics. |
| Early toxicity | Nausea, diarrhoea, coarse tremor, thirst, polyuria, weakness, ataxia, slurred speech and increasing confusion. |
| Severe toxicity | Marked tremor, hyperreflexia, seizures, reduced consciousness, dysrhythmia or renal failure. Do not induce vomiting; withhold further doses pending urgent clinician/poison-centre advice and support ABCDE. |
| Patient education | Keep fluid and salt intake steady, avoid unsupervised NSAIDs, report persistent vomiting/diarrhoea or fever, and never double a missed dose without advice. |
Valproate (sodium valproate/valproic acid)
- Used for mania and epilepsy; common effects include nausea, tremor, sedation, weight gain and hair changes.
- Serious toxicity includes hepatotoxicity, pancreatitis, thrombocytopenia, hyperammonaemic encephalopathy and coma.
- Check for abdominal pain, persistent vomiting, jaundice, bruising, confusion or reduced consciousness; arrange urgent laboratory review.
- It carries major fetal risk. It should not be used for bipolar maintenance in women and girls of childbearing potential where safer effective alternatives are available; pregnancy decisions require specialist review, not abrupt stopping.
Carbamazepine and lamotrigine
| Medicine | Key cautions | Red flags for urgent referral |
|---|---|---|
| Carbamazepine | Diplopia, ataxia, hyponatraemia, hepatic injury, leukopenia, aplastic anaemia, rash and multiple interactions through enzyme induction. | Seizure, severe ataxia, confusion, syncope, mucosal rash, fever/sore throat, jaundice or overdose. |
| Lamotrigine | Slow titration is essential; missed doses may require re-titration. Interaction with valproate increases lamotrigine exposure. | Any blistering rash, mucosal ulceration, facial oedema, fever or systemic illness suggests Stevens–Johnson syndrome/toxic epidermal necrolysis. |
“LITHIUM = RENEW”: Renal function, Electrolytes/fluid balance, Neurological signs, Endocrine/thyroid, Warnings from interacting medicines. A normal-looking patient can deteriorate after dehydration or a new NSAID.
7. Anxiolytics, hypnotics and sedative medicines
Benzodiazepines (diazepam, lorazepam, midazolam and related agents) enhance GABA-A activity. They can be lifesaving for prolonged seizures, severe alcohol withdrawal and carefully monitored procedural sedation. They are also common causes of falls, aspiration, respiratory depression, dependence and difficult withdrawal. The danger increases when combined with opioids, alcohol, sedating antihistamines or other CNS depressants.
| Situation | What the EMT should look for | Safety action |
|---|---|---|
| Therapeutic sedation | Increasing drowsiness, reduced airway tone, slow/shallow breathing, hypotension. | Continuous observation, oxygen/ventilation readiness, suction and reversal/advanced support according to local protocol. |
| Benzodiazepine overdose | Ataxia, slurred speech, somnolence, hypoventilation or coma; mixed ingestion is common. | ABCDE and glucose; protect airway. Flumazenil is not routine and may precipitate seizures or withdrawal in dependent patients or mixed TCA overdose. |
| Alcohol withdrawal | Tremor, sweating, anxiety, tachycardia, hypertension, hallucinations, seizures or delirium tremens. | Urgent medical care, glucose/thiamine considerations, calm environment, seizure precautions and protocol-led benzodiazepine treatment. |
| Withdrawal after long use | Rebound anxiety/insomnia, tremor, perceptual changes, seizures and delirium. | Never advise abrupt cessation; communicate the last dose and arrange supervised tapering. |
8. Acute agitation, psychosis and mania
Agitation ranges from anxiety and pacing to excited delirium-like states with immediate danger. Treat the person as medically unwell until reversible causes are considered. A calm approach is clinically effective and preserves dignity.
A practical emergency sequence
- Make the scene safe: remove weapons and bystanders, keep an exit route, use trained staff and request security/police support only for safety—not punishment.
- Introduce and listen: one lead communicator, short sentences, non-threatening posture, respectful name/pronouns and validation of distress without agreeing with delusions.
- Rapid medical screen: airway, breathing, circulation, glucose, temperature, oxygen saturation, trauma, toxidromes, infection, pain, urinary retention and medication/withdrawal history.
- Offer choices: quiet room, trusted relative, oral medicine if prescribed and accepted, or transport for assessment. Explain what will happen.
- Escalate early: senior clinician, mental-health team, toxicology or critical care if violence, severe psychosis, delirium, hyperthermia, hypoxia, seizure, intoxication or self-harm risk is present.
- Monitor after any sedative: respiratory rate, SpO2, pulse, blood pressure, temperature, level of consciousness, ECG where indicated and the time/dose/route of every medicine.
Never diagnose delirium as “psychiatric.” New fluctuating inattention, disorientation, visual hallucinations, fever, abnormal vital signs or altered consciousness suggests a medical/toxic cause and needs urgent investigation.
9. Medicines in substance-related emergencies
Opioid toxicity and naloxone
Suspect opioid toxicity in a person with pinpoint pupils, reduced consciousness and slow or absent breathing. Call for help, open the airway, provide rescue ventilation/oxygen and give naloxone according to the available local protocol. Naloxone may wear off before a long-acting opioid; recurrent respiratory depression requires observation and repeat treatment by trained clinicians. Sudden awakening can produce vomiting, agitation, pain and acute withdrawal—protect the patient and staff while continuing to monitor breathing.
Alcohol and sedative withdrawal
Withdrawal can be fatal. Ask when alcohol or sedatives were last used, previous withdrawal seizures/delirium, daily quantity and co-use of opioids. Tremor, autonomic instability, hallucinations, seizures or confusion requires urgent medical management. Do not give an isolated sedative dose without monitoring and a protocol.
10. Intentional overdose and self-harm
Use a non-judgmental, private approach. Ask directly whether the ingestion was intentional, what was taken, how much, when, and whether other substances were involved. Bring packets, bottles, prescriptions or photographs. Do not wait for symptoms: some medicines have delayed cardiotoxicity, seizures, liver injury or serotonin/NMS complications.
| Priority | Action |
|---|---|
| Immediate threats | ABCDE, glucose, temperature, oxygen saturation, ECG, IV access where trained, seizure precautions and poison-centre/medical consultation. |
| Decontamination | Do not induce vomiting. Activated charcoal or other decontamination is clinician/poison-centre-led and depends on timing, substance, airway protection and contraindications. |
| Risk and safeguarding | Ask about ongoing suicidal intent, access to medicines/weapons, violence, dependants, pregnancy and whether the person is safe to leave. Maintain observation and remove immediate means. |
| Handover | State exact agent, formulation, dose estimate, time, co-ingestions, symptoms, vital trends, ECG findings, treatment and response. |
11. Suicide-risk communication and safety planning
Ask clearly: “Have you wished you were dead?”, “Have you thought about killing yourself?”, “Do you have a plan, access to the means and an intention to act?” Asking does not create suicidal thoughts; it identifies danger. Listen without arguing, promise only what you can deliver, involve a trusted support person with consent where safe, and arrange urgent mental-health assessment for current intent, recent attempt, severe depression, psychosis, intoxication, inability to collaborate or lack of a safe environment.
Safety-plan essentials: warning signs; internal coping strategies; people and places that provide distraction; trusted people to contact; professional/crisis contacts; and practical removal or restriction of medicines, pesticides, weapons and other lethal means. Document who will supervise medicines and when follow-up will occur.
12. High-risk adverse reactions: recognition and first actions
| Reaction | Clues | What to do now |
|---|---|---|
| Serotonin syndrome | Recent serotonergic combination or overdose; agitation, sweating, diarrhoea, tremor, clonus/hyperreflexia, fever and tachycardia. | ABCDE, stop suspected agents under medical direction, remove excess heat, IV/monitoring support and urgent senior/toxicology review. |
| Neuroleptic malignant syndrome | Dopamine blocker; lead-pipe rigidity, hyperthermia, altered consciousness, autonomic instability and raised CK. | Emergency transfer, cooling, airway/ventilation readiness, fluids and critical-care management. |
| Acute dystonia | Oculogyric crisis, torticollis, jaw spasm, dysphagia or laryngospasm after antipsychotic/antiemetic. | Airway assessment and urgent protocol-led anticholinergic treatment. |
| Severe akathisia | Subjective inner torment and pacing soon after antipsychotic change; may mimic anxiety or worsening psychosis. | Do not dismiss or automatically escalate antipsychotic; urgent prescriber review and suicide-risk screen. |
| Anticholinergic delirium | Hot, dry skin, dilated pupils, tachycardia, urinary retention, ileus, hallucinations and confusion. | ABCDE, temperature/ECG/glucose, cooling and toxicology/medical advice; avoid physical struggle if possible. |
| Severe hyponatraemia | Headache, nausea, confusion, seizures or reduced consciousness; possible with SSRIs, carbamazepine or diuretics. | Seizure precautions and urgent medical/laboratory management; do not rapidly correct without protocol. |
| Clozapine-related infection/myocarditis | Fever, sore throat, malaise, chest pain, dyspnoea, palpitations or unexplained tachycardia. | Urgent medical review, FBC/inflammatory/cardiac tests as directed and do not assume a benign viral illness. |
13. Medication history for the psychiatric emergency
| Question | Why it changes care |
|---|---|
| What medicines, strengths and formulations are taken? | Identifies long-acting injections, modified-release products, high-risk agents and duplicate therapy. |
| When was the last dose? Any missed doses or recent changes? | Separates withdrawal, relapse, adverse effect and delayed toxicity. |
| Any alcohol, opioids, stimulants, cannabis or herbal products? | Mixed intoxication/withdrawal changes airway, seizure and interaction risk. |
| Kidney, liver, heart, epilepsy, diabetes or pregnancy? | Changes clearance, QT risk, metabolic monitoring and medicine choice. |
| Previous reactions or suicide attempts? | Predicts recurrence and informs safe transport, observation and safeguarding. |
| Who prescribes and where are records? | Enables accurate reconciliation and prevents unsafe duplication or abrupt interruption. |
14. Special populations
- Children and adolescents: use weight-appropriate, protocol-led dosing; assess safeguarding, developmental context, accidental ingestion and emerging suicidal thoughts. Avoid adult assumptions.
- Older adults: start low and monitor slowly; renal impairment, falls, delirium, anticholinergic burden and QT prolongation are common hazards.
- Pregnancy and breastfeeding: do not abruptly stop effective treatment. Rapidly involve obstetric and mental-health clinicians; valproate has major fetal risk and lithium needs specialist risk–benefit monitoring.
- Renal or hepatic disease: reduced clearance can turn a normal dose into toxicity. Ask for recent creatinine/LFTs and report the condition in handover.
- People with disabilities or communication barriers: use accessible language, hearing/visual aids, a support person and behavioural baseline; do not mistake communication differences for psychosis.
- People experiencing homelessness or poverty: treatment adherence may be limited by food, transport, storage and safety. Link to social and community services rather than labelling “non-compliant.”
15. Common interactions worth remembering
| Combination/problem | Potential harm | EMT teaching point |
|---|---|---|
| SSRI/SNRI + MAOI, linezolid, tramadol, lithium or St John’s wort | Serotonin syndrome. | Ask specifically about new antibiotics, analgesics and herbal products. |
| Lithium + NSAID, ACE inhibitor/ARB or thiazide | Raised lithium concentration and toxicity. | Dehydration plus a “routine” pain medicine can be the trigger. |
| Antipsychotic + other QT-prolonging medicine or hypokalaemia | Torsades de pointes and syncope. | ECG and electrolyte review are important before/after emergency sedation. |
| Opioid + benzodiazepine/alcohol | Synergistic respiratory depression and death. | Prioritise breathing; provide naloxone/ventilation according to protocol. |
| Valproate + lamotrigine | Increased lamotrigine exposure and severe rash risk. | Any mucosal or blistering rash is an emergency. |
| Clozapine + smoking cessation or infection | Metabolic changes can raise clozapine exposure and toxicity. | Report sudden smoking change, fever, seizures, sedation or constipation. |
16. Clinical scenarios for EMT students
Scenario 1 — “The restless patient after a dose increase”: A patient on risperidone paces continuously, says they cannot keep still and has new suicidal thoughts. Vital signs are stable. Consider akathisia rather than “non-cooperation”; maintain safety, ask about self-harm, notify the prescriber and document the recent dose change.
Scenario 2 — “Hot and rigid”: A patient treated with haloperidol develops 40°C temperature, severe rigidity, confusion and tachycardia. Treat as NMS until proved otherwise: ABCDE, urgent transfer, cooling, IV/critical-care support and immediate medication review.
Scenario 3 — “Vomiting on lithium”: A patient with bipolar disorder has diarrhoea, coarse tremor, ataxia and slurred speech after several days of poor intake and ibuprofen use. Suspect lithium toxicity, protect from falls, withhold further unsupervised doses, bring the medication packet and seek urgent laboratory/toxicology advice.
Scenario 4 — “Several serotonergic tablets”: After taking an SSRI with tramadol, a patient has agitation, sweating, tremor and inducible clonus. Manage airway/breathing/circulation, temperature and seizures, stop further serotonergic exposure under clinician direction and arrange urgent toxicology care.
Scenario 5 — “Psychosis with low glucose”: A confused, shouting patient has a glucose of 2.4 mmol/L. Correct the life threat under protocol and reassess before labelling the behaviour psychosis. A medical cause can coexist with a psychiatric history.
17. Documentation and handover checklist
- Baseline mental state, orientation, speech, behaviour, risk statements and capacity/consent where relevant.
- Exact medicine names, strengths, formulation, route, prescribed dose, last dose, missed doses, allergies and recent changes.
- Alcohol/recreational drug history, pregnancy possibility, kidney/liver/heart disease, epilepsy, diabetes and previous adverse reactions.
- Vital-sign trends, glucose, temperature, oxygen saturation, ECG findings, neurological signs, fluid intake/output and injury assessment.
- De-escalation attempted, who was present, medicines administered (time/route/dose), response and adverse effects.
- Suicide/violence/self-neglect risk, access to means, safeguarding concerns, family/support person and agreed safety plan.
- Destination, receiving clinician, advice received and exact time of handover.
18. Patient and family education
- Explain the purpose of each medicine in plain language and state when benefit is expected.
- Give a simple missed-dose plan from the prescriber/pharmacist; never “catch up” by doubling without advice.
- Explain which symptoms require urgent help: breathing difficulty, collapse, severe rash, fever/rigidity, seizures, fainting, severe confusion, suicidal intent, jaundice, chest pain or persistent vomiting.
- Encourage one pharmacy/medicine list and safe storage away from children and anyone at risk of overdose.
- Warn against mixing sedatives with alcohol or opioids and against sharing prescribed medicines.
- For lithium and other monitored drugs, keep appointments for blood tests and report dehydration, new medicines or major diet/fluid changes.
Exam and practice point: A normal blood pressure does not make a sedated patient safe. Airway tone and ventilation may deteriorate before the monitor alarm. Reassess after every intervention and after every change in consciousness.
19. Quick comparison: when to suspect which emergency?
| Presentation | Most useful clues | Priority |
|---|---|---|
| Agitated + sweaty + clonus | Serotonergic drug/interaction, hyperreflexia, diarrhoea. | Serotonin syndrome; ABCDE, cooling, urgent toxicology. |
| Agitated + rigid + very hot | Dopamine blocker, lead-pipe rigidity, autonomic instability. | NMS; emergency transfer and critical-care support. |
| Drowsy + slow breathing | Opioid, benzodiazepine, alcohol or mixed ingestion. | Airway/ventilation, glucose, naloxone where opioid toxicity suspected. |
| Confused + dry + dilated pupils | Anticholinergic medicines, urinary retention, ileus, tachycardia. | Toxicological emergency; ECG, temperature and medical review. |
| Tremor + diarrhoea + ataxia | Lithium exposure, dehydration, NSAID/ACE inhibitor/thiazide use. | Withhold further unsupervised doses and obtain urgent level/renal assessment. |
| New psychosis + fluctuating attention | Delirium, infection, hypoxia, glucose/electrolyte problem or intoxication. | Search for a medical cause; do not treat as primary psychosis alone. |
20. Revision questions
- Why can a patient with serotonin syndrome have clonus and diarrhoea while a patient with NMS has marked rigidity?
- List four factors that can increase lithium concentration and name four early toxicity findings.
- What are the first five actions when a person is severely agitated in the ambulance bay?
- Why is flumazenil not a routine antidote for every benzodiazepine overdose?
- Which antipsychotic adverse effect presents as painful neck spasm or oculogyric crisis?
- Why must glucose and oxygenation be checked before diagnosing a behavioural emergency?
- What information must accompany a handover after intentional psychotropic ingestion?
- How does an EMT distinguish akathisia from “worsening psychosis”?
- What counselling is important for a patient taking valproate who may become pregnant?
- Describe the components of a practical safety plan after self-harm.
21. Key take-home points
- Psychiatric symptoms can be caused or amplified by hypoxia, glucose/electrolyte disturbance, infection, trauma, intoxication, withdrawal or medicine toxicity.
- Antidepressants need time and monitoring; combinations can cause serotonin syndrome and abrupt cessation can cause withdrawal.
- Antipsychotics can cause movement disorders, QT prolongation, metabolic disease and life-threatening NMS.
- Lithium is effective but unforgiving: hydration, renal function, salt balance and interactions matter.
- Valproate, carbamazepine and lamotrigine require liver/blood/rash and pregnancy safety vigilance.
- Benzodiazepines can save lives in seizures and withdrawal but can suppress breathing, especially with opioids or alcohol.
- Respectful de-escalation, least-restrictive care, direct suicide questions and careful documentation are core emergency skills.
Selected authoritative learning resources
- WHO Mental Health Gap Action Programme (mhGAP) — evidence-based guidance for non-specialist settings.
- WHO psychosis and bipolar evidence centre — antipsychotics and mood-stabiliser recommendations.
- NICE psychosis and schizophrenia guideline — antipsychotic choice, monitoring and clozapine.
- WHO self-harm and suicide evidence — safety planning and follow-up.
For EMT practice: Treat every medicine as both a therapeutic tool and a potential source of harm. A calm voice, complete medication history, repeated physiological assessment and early senior consultation prevent more deaths than a rushed label.