Author: Don Stader, MD
- Recent study showed efficacy 5mg IM midazolam > 10mg IM olanzapine > 10mg IM haloperidol for quickly sedating an agitated patient
- If you have access, ketamine intravenous is the fastest
- Olanzapine should be used with caution in elderly patients because of its anticholinergic properties
- Ketamine can transiently worsen psychosis in some mental illness
- Haloperidol is contraindicated in patients with prolonged QT
- Olanzapine can be safely given intravenous as another option to your sedating arsenal
Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, Horton GB, Fagerstrom E, Satpathy R, Cole JB. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):374-385. doi: 10.1016/j.annemergmed.2018.04.027. Epub 2018 Jun 7. PubMed PMID: 29885904.
Chew ML, Mulsant BH, Pollock BG, Lehman ME, Greenspan A, Kirshner MA, Bies RR, Kapur S, Gharabawi G. A model of anticholinergic activity of atypical antipsychotic medications. Schizophr Res. 2006 Dec;88(1-3):63-72. Epub 2006 Aug 22. PubMed PMID: 16928430.
Mankowitz SL, Regenberg P, Kaldan J, Cole JB. 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 Nov;55(5):670-681. doi: 10.1016/j.jemermed.2018.07.017. Epub 2018 Sep 7. PubMed PMID: 30197153.
Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD
Check out this episode!
Author: Gretchen Hinson, M.D.
- PNES vs. epilepsy: postictal state is diagnostic of an epileptic seizure (sonorous respirations and/or confusion, lasting typically 20-30 minutes); Epileptiform seizures show decrease in convulsion frequency, but increase in convulsion amplitude while PNES convulsions demonstrate episodic convulsion amplitudes; and epileptiform seizures usually do not pause.
- PNES is a form of conversion disorder and can be associated with underlying personality disorder; however there are patients with epilepsy that also can have PNES which complicates the diagnosis and treatment.
- Patients that are malingering may have flailing movements and might talk during the episodes – both not typical of epileptic seizures or PNES.
- Treatment for PNES is with psychotropic medications and psychotherapy as opposed to antiepileptic medications
Avbersek, A; Sisodiya, S. (2010). Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?. Journal of neurology, neurosurgery, and psychiatry. 81(7):719-25.
Devinsky, O; Gazzola, D; LaFrance, W. Curt (2011). Differentiating between nonepileptic and epileptic seizures. Nature Reviews. Neurology. 7 (4): 210?220.
Lesser, RP. (2003). Treatment and Outcome of Psychogenic Nonepileptic Seizures. Epilepsy Currents. 3(6):198-200. doi:10.1046/j.1535-7597.2003.03601.x.
Pillaia, JA; Hautab SR. (2012). Patients with epilepsy and psychogenic non-epileptic seizures: An inpatient video-EEG monitoring study. Seizure. 21(1): 24-27.
Author: Dylan Luyten, MD
- Johannes Hoffer coined term Nostalgia in 1688 in his medical dissertation.
- Nostalgia was a formal medical diagnosis, and one that dates back to 17th century when soldiers had longing for home and melancholy with a constellation of symptoms including lethargy, sadness, disturbed sleep, heart palpitations, GI complaints, and/or skin findings for which the only cure was to return home.
- In the civil war, over 5000 soldiers were given medical leave for nostalgia.
- Always remember to view your patient in the appropriate context (psychosocial, cultural, historical, etc.)
Beck, J. (2013, August 14). When Nostalgia Was a Disease. Retrieved March 08, 2018, from https://www.theatlantic.com/health/archive/2013/08/when-nostalgia-was-a-disease/278648/
Podcast #221: Walking Corpse Syndrome
Author: Erik Verzemnieks, M.D.
- Walking Corpse Syndrome (aka Cotard Delusion) is a very rare psychiatric disorder that leads to the belief that one is a “walking corpse”.
- Often co-presents with depression, schizophrenia, and starvation.
- Responds to ECT.
Run Time: 4 minutes
Author: Dr. Michael Hunt
- Ketamine is a dissociative anesthetic that can be used for sedation, anesthesia, or to calm down agitated patients.
- Can be given IV at 1-2 mg per kilo or IM at 4-5 mg per kilo every ten minutes and will last anywhere from five to thirty minutes depending on administration.
- Complications include laryngospasm (1%), increased IC pressure, increased ocular pressure, rash (15%), and acute psychosis.
Link to Podcast: http://medicalminute.madewithopinion.com/ketamine/