Abstract
Background
Ketamine's application in psychiatry have expanded, but it appears never to have been
previously used to diagnose and treat patients with catatonia-like syndrome that occasionally
present to emergency departments.
Case Report
A 23-year-old male was observed to suddenly stop talking. His ED GCS was 8 and had
normal vital signs. While verbally unresponsive, he refused to open his eyes, demonstrated
waxy flexibility of his arms, but the balance of his physical, neurological, and laboratory
exams were normal. Strongly suspecting a catatonic state, they needed to rapidly confirm
that diagnosis or begin evaluating him for potentially life-threatening non-psychiatric
illnesses. Lacking other diagnostic modalities, they administered low-dose ketamine
boluses. Ketamine 25 mg (1 mL) was diluted in 9 mL NS (2.5 mg/mL). Based on similar
protocols, 1 mL of the solution (0.03 mg/Kg) was given intravenously every few minutes.
After 12.5 mg ketamine, he was conscious and verbal. Subsequent history confirmed
a prior episode requiring an extensive, non-productive medical evaluation. Psychiatry
later confirmed the diagnosis.
Why Should an Emergency Physician Be Aware of This?
Patients with catatonia-like states pose a difficult diagnostic and therapeutic dilemma.
Multiple interventions have been used with varying success. Optimal interventions
provide a rapid resolution (or demonstrate that a psychiatric cause is not likely),
be safe, encompass few contraindications, and be familiar to the clinician. In our
patient, subanesthetic doses of ketamine fulfilled these criteria and successfully
resolved the condition. If shown effective in other cases, ketamine would be a valuable
addition to our psychiatric armamentarium.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Emergency MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The THINK (Treatment of Headache with Intranasal Ketamine) trial: a randomized controlled trial comparing intranasal ketamine with intravenous metoclopramide.J Emerg Med. 2019; 56: 248-257
- Repeat intravenous ketamine dosing in children undergoing emergency department procedural sedation.J Emerg Med. 2019; 56: 1-6
- Ketamine for rapid sedation of agitated patients in the prehospital and emergency department settings: a systematic review and proportional meta-analysis.J Emerg Med. 2018; 55: 670-681
- Motor features in psychotic disorders II.Schizophr Res. 2001; 47: 117e26
- Measuring catatonia: a systematic review of rating scales.J Affect Disord. 2011; 135: 1-9
- The emergency amobarbital interview.Ann Emerg Med. 1980; 9: 513-517
- Response of chronic neuropathic pain. syndromes to ketamine: a preliminary study.Pain. 1994; 56: 51-57
- Catatonia-like symptomatology: an interesting case.Arch Gen Psychiatry. 1971; 24: 119-120
- Catatonia: disappeared or under-diagnosed?.Psychopathology. 2005; 38: 3-8
- Catatonia: A Clinician’s Guide to Diagnosis and Treatment.Cambridge University Press, Cambridge2003
- Catatonia: From Psychopathology to Neurobiology.American Psychiatric Publishing, Washington, DC2004
- Herpes encephalitis with catatonic stupor.Arch Gen Psychiatry. 1974; 31: 544-546
- Catatonic behavior, viral encephalopathy, and death: the problem of fatal catatonia.Arch Gen Psychiatry. 1972; 27: 758-761
- Catatonic syndrome in a case of subdural hematoma.J Nerv Ment Dis. 1953; 117: 123-129
- Catatonic stupor in elderly woman with hyperparathyroidism.Br Med J. 1966; 1: 85-87
- Catatonia and hepatic dysfunction.Dis Nerv Syst. 1976; 28: 606-608
- Cerebral systemic lupus erythematosus presenting with catatonia.Postgrad Med J. 1985; 61: 329-330
- Late-onset Tay-Sachs disease presenting as catatonic schizophrenia: diagnostic and treatment issues.J Clin Psychiatry. 1995; 56: 347-353
- Multiple sclerosis presenting as catatonia.Int J Psychiatry Med. 1999; 29: 435-441
- Catatonia: diagnosis and management.Hosp Community Psychiatry. 1975; 26: 91-94
- Sudden catatonic stupor with disastrous outcome.JAMA. 1977; 238: 618-620
- Why do neurologists miss catatonia in neurology emergency? A case series and brief literature review.Clin Neurol Neurosurg. 2019; 184: 105375
- Catatonia in DSM-5: controversies regarding its psychopathology, clinical presentation and treatment response.Neuropsychopharmacol Hung. 2014; 16: 189-194
- Diagnostic and Statistical Manual of Mental Disorders (DSM-5).American Psychiatric Association Publishing, Washington, DC2013
- Plasma homovanillic acid concentrations in catatonia.Biol Psychiatry. 1996; 39: 436-443
- Effects of quetiapine on monoamine, GABA, and glutamate release in rat prefrontal cortex.Psychopharmacology (Berl). 2009; 206: 243-258
- Systematic review of catatonia treatment.Neuropsychiatr Dis Treat. 2018; 14: 317
- Use-dependent block of excitatory amino acid currents in cultured neurons by ketamine.J Neurophysiol. 1987; 58: 251-266
- Catatonia and the immune system: a review.Lancet Psychiatry. 2019; 6: 620-630
- Ketamine and ketamine metabolite pharmacology: insights into therapeutic mechanisms.Pharmacol Rev. 2018; 70: 621-660
- The pharmacotherapy of catatonia.Primary Psychiatry. 2010; 17: 41
- A prospective randomized, double-dummy trial comparing IV push low dose ketamine to short infusion of low dose ketamine for treatment of pain in the ED.Am J Emerg Med. 2017; 35: 1095-1100
- Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists.Reg Anesth Pain Med. 2018; 43: 456-466
Article info
Publication history
Published online: January 27, 2020
Accepted:
December 22,
2019
Received in revised form:
December 19,
2019
Received:
September 8,
2019
Footnotes
Reprints are not available from the authors.
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
