Neurology

Catatonia

Case

An 82 year-old female presents to the ED with her daughter due to altered mental status. On EMS arrival to the patient’s home, she is somnolent and unable to speak. She is activated as a Code Stroke and brought immediately to CT scan upon arrival. After returning from the CT scan, you go in to perform a comprehensive neurologic exam. The patient is lying in bed with her eyes closed, she does not arouse to voice. She does grimace with painful stimulation such as sternal rub. She groans and mumbles words but does not make coherent sentences. She does not follow commands. Her extremities do localize to painful stimulation. Despite her concerning neurologic exam, she is maintaining O2 saturations at 98% on room air and a respiratory rate of 14 with full deep breaths. While performing her neurologic exam, you lift her arm into the air and she holds it there indefinitely until you move the arm again. The radiologist calls to inform you of her normal non-contrast CT and CTA of the brain and neck. All laboratory work returns reassuring. On re-examination, she continues leave her limbs in the exact position you place them in until re-positioned. This reminds you of a condition that you learned about in medical school… catatonia!


Clinical Presentation

Catatonia is a syndrome characterized by psychomotor abnormalities and often associated with a variety of psychiatric and neurologic conditions, classically schizophrenia. The syndrome can present with a variety of psychomotor symptoms and often decreased mental state. Although it was originally thought to be associated solely with schizophrenia, it has now been found to be associated with any psychiatric condition including PTSD, bipolar disorder, depression as well as neurologic conditions such as encephalitis, stroke, malignancy, or dementia. Catatonia can be a difficult diagnosis to make due to a variety of presentations. Some of the classic features of catatonia are listed below.


In the DSM-V definition of catatonia, the patient must present with at least three of the following:

  • Stupor – overall decreased activity or decreased interaction with the environment

  • Catalepsy – muscular rigidity, i.e. a limb stays where it is positioned

  • Waxy flexibility – resistance to positioning, like a feeling of bending a candle

  • Mutism – no verbal response

  • Negativism – no response to external stimuli

  • Posturing – maintaining a specific position for prolonged periods of time

  • Mannerisms – odd movements

  • Stereotypy – repetitive movements

  • Agitation

  • Grimacing

  • Echolalia – mimicking speech

  • Echopraxia – mimicking movements


Diagnosis

The diagnosis of catatonia is based on recognition of these classic clinical findings. Appropriate medical workup to exclude organic etiology is also very important. For example, common mimics could include acute intracranial processes such as ischemic or hemorrhagic stroke, meningitis/encephalitis, electrolyte derangement, neuroleptic malignant syndrome, serotonin syndrome, delirium, and many other causes. Consideration to medical workup to exclude these causes is of utmost importance to make the diagnosis and not miss a life-threatening process. Detailed history and physical exam should be performed, including specific attention to complete neurologic exam, evaluation of reflexes, and any signs of autonomic instability. Additional testing should include broad laboratory work, brain imaging including CT or MRI, and consideration of CSF studies.

 

Treatment

Once a diagnosis of catatonia is suspected, the treatment should be initiated as soon as possible. The simplest treatment for an ED physician to perform is termed the “benzodiazepine challenge.” This can help with diagnostic uncertainty and rapidly improve symptoms in a majority of patients. Lorazepam is most often cited as the agent of choice due to its evaluation in the literature and the ease of use for ED physicians. It is estimated that about 60-80% of patients will achieve remission with benzodiazepine monotherapy. In a patient with suspect catatonia, the ED physician can give 2 mg IV lorazepam and observe the patient. Rapid improvement can be seen in their symptoms within a few minutes. After approximately 20-30 minutes, the patient may have recurrence of their catatonia symptoms and regress. Additional IV lorazepam can be given as needed. Besides IV benzodiazepines, the alternative treatment of choice is ECT. This should be started as soon as feasible, ideally within 24 to 48 hours of diagnosis. Antipsychotic drugs should be avoided in patients with catatonia, even for aggression or agitated patients.  If not properly and promptly treated catatonia can proceed to malignant catatonia which carriers an associated mortality of up to 20%.

 

Disposition

All patients with suspected diagnosis of catatonia should be admitted to the hospital for aggressive management of catatonia as well as the underlying psychiatric or medical disorder. Patients who have autonomic instability or hyperthermia should be admitted to the intensive care unit for close supportive care. Long term catatonia carriers a favorable prognosis.

 

Case Conclusion

Our patient was given a single dose of 1 mg IV lorazepam and soon after, began to speak and interact with her daughter, who had accompanied to the ED. Within one hour, she had return of mutism and cataplexy so an additional dose of IV lorazepam was given with rapid improvement of her symptoms. She was admitted to internal medicine with psychiatry consulting and was transitioned to an oral lorazepam regimen. She ultimately had good recovery and was discharged back to home with her daughter after an inpatient stay.

  

Teaching points

  • Catatonia is a purely clinical diagnosis that can be made in the ED

  • Recognize the characteristic clinical findings to keep this syndrome on your differential diagnosis of patients with mental changes

  • The treatment of catatonia should be initiated in the ED with IV lorazepam and rapid clinical improvement can help confirm your diagnosis


Faculty Reviewer: Dr. Kristina McAteer


References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013

  2. Fink, Max, and Michael A. Taylor. "The many varieties of catatonia." European archives of psychiatry and clinical neuroscience 251.1 (2001): I8-I13.

  3. HUANG, TIAO‐LAI. "Lorazepam and diazepam rapidly relieve catatonic signs in patients with schizophrenia." Psychiatry and clinical neurosciences 59.1 (2005): 52-55.

  4.  Jaimes-Albornoz, Walter, and Jordi Serra-Mestres. "Catatonia in the emergency department." Emerg Med J (2012): emermed-2011. 

  5. Sharma, Puja, et al. "Catatonia in patients with dementia admitted to a geriatric psychiatry ward." Journal of neurosciences in rural practice 8.Suppl 1 (2017): S103.

  6. Wilcox, James Allen, and Pam Reid Duffy. "The syndrome of catatonia." Behavioral Sciences 5.4 (2015): 576-588.

Asynchrony EM: Code Stroke

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM, with digital content curated into topic modules following our curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM professional community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section.

Click here for more about us and for other curated teaching modules!

Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

 

This week in Asynchrony, we discuss code stroke.   Recognition of stroke is something ED practitioners must become very good at, however it is hard --and sometimes making the call can be difficult! 

We have a LOT of great #FOAMed content listed -- take your time and enjoy. Stroke mimics, posterior strokes, tPA (both recent data and old controversies, main line and endovascular) -- we've got it all here for you!

But before we wade into the velvet sea of 'code strokes', take a listen to a musical selection that could be aptly described as self-induced stroke symptoms from the consumption of stimulants followed by...whatever:

From EM Docs: how to recognize stroke and develop your ddx highlighting stroke mimics 

From Life in the Fast Lane - a succinct review of must know data & review of literature

"Stroke and TIA: Pearls and Pitfalls", again from EM Docs. Excellent review that helps you organize the management steps of stroke and gives treatment options (along w literature references - BONUS!!) to help streamline your approach 

From REBEL EM - summary of avail  lit to date focusing on effects of TPA

Another option on the data and rational for TPA usage -  from Life in the Fast Lane

 

Endovascular TPA

a) Drastic changes came to the landscape in 2014, when one of the first major positive trials for endovascular therapy emerged – the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN). This study ushered in the new era in endovascular intervention.

Endovascular Stroke Therapy: The New Standard? - studies showing support for intravascular TPA

b) While the data may have been promising, the truth is that a limited population will actually benefit from the therapy. The trials focused on patients with severe strokes, with large vessel occlusions and salvageable brain tissue -- however this is a small portion of the stroke patients arriving to our EDs. 

A Word of Caution, from PulmCrit

c) Time to get a little wild & crazy... you think risk factors for vascular disease in our pediatric population are unlikely but they can have strokes too --BEWARE!!  - Pediatric Stroke: EM Focused Highlights (EM Docs)

d) The ever challenging and elusive posterior stroke - an EM Crit Podcast

e) Featuring HINTS and more on posterior strokes - Posterior Stroke and HINTS exam, EM Docs

f) HINTS Demo if you need it however if test of skew is your thing, then feel free to jump ahead!

HINTS Demonstration

 

The EXTRAS!! 

a) New information, will our stroke management change soon?  Data on the approach via low dose TPA. From EM Crit: The Case of the Non Inferior Inferiority Continues.

b) A bit older information and data you probably know well.  The following links highlight the history of how TPA came to be an accepted treatment for stroke and the very evidence you use to justify your decision in administering this drug...

The Secret of NINDS, from the SGEM - excellent review of the NINDS study that started the whole TPA regime.

c) The fragility of the NINDS - from PulmCrit

d) From 2014, EM Crit  - an animated and entertaining review of NINDS trial and limitations of the trail that has served as the basis for TPA use.  (Discussion of consent.)

e) EM Cases: Information on the ABCD2 score (if you are using it:) and more!

That's it! See you next time in Asynchrony EM  -- happy #FOAMing!

Asynchrony EM: Seizure Sampler

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM. Digital resources and #FOAMed are curated and packaged by topic, following Brown EM's curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM community at large. Check out the theme song, the 'extras', and the discussion questions, and other modules -- and leave us your thoughts in the comments section. Follow us on Twitter at @AsynchronyEM.
Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

 

This week in Asynchrony we're still in the Neuro/HEENT/Psych block (and will be until June!) Today we've got some must-know core content on seizures in the ED. Adults, kids, pregnant people -- we're covering lots of bases!

But no week in Asynchrony is complete without a theme song. This week: Shake It Off! (I'm just gonna shake shake shake shake shake shake...)

Haters gonna hate hate hate...learners gonna learn learn learn. Let's go!

1) From Core EM: ED Management of Seizures. Maybe not every first time seizure needs a head CT...more in our discussion section.  Also, the jump to propofol for refractory SE is not a universal choice, although it is becoming more widely accepted (see EM Lyceum below --a couple of years old, and nary a mention of propofol. But it's definitely a thing now.)

 

2) ACEP Clinical Policy on Adult Seizures (2014). Four questions:

  • In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the emergency department to prevent additional seizures?
  • In patients with a first unprovoked seizure who have returned to their baseline clinical status in the emergency department, should the patient be admitted to the hospital to prevent adverse events?
  • In patients with a known seizure disorder in which resuming their antiepileptic medication in the emergency department is deemed appropriate, does the route of administration impact recurrence of seizures?
  • In emergency department patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures? 

 

3) Four more questions from EM Lyceum . Click on the small link in the upper right to go from 'questions' to 'answers.'

  • Which benzodiazepine do you prefer for the treatment of status epilepticus (SE)? Which do you prefer for pediatric patients?
  • Which second-line agents do you use for treatment of SE?
  • In which adult patients with first-time seizure do you obtain emergent imaging?
  • How do you diagnose pseudoseizure (PNES)?

 

4) Don't forget to factor in medications/drugs that can contribute to or outright cause seizures, either in therapeutic use (by lowering the seizure threshold), in overdose (such as TCA's) or with elevated levels caused by drug interactions, or by withdrawal(benzos, alcohol).  Or by any combination of the above. 

Drug-induced Seizures: from MedScape/USPharmacist 2014.  Just read page 6 (the linked page) and click through to table 3 at the end of the article for a list of commonly implicated drugs.

Note that missing from the Medscape table are the QUINOLONE antibiotics which also can also lower the seizure threshold (browse this EP Monthly article and specifically read the section on neurologic complications of therapy.)  

Aside: Don't forget to ask family or rescue or whoever can help you to double check the house for meds/drugs when things just don't add up. I learned that for the oral boards, but it's saved the day a couple of times for me in practice.

 

5) When the patient doesn't come back to their right mind, keep this in yours: Non-convulsive Status Epilepticus . What could you be missing? From EM Docs.

Now on to the kiddos!

6a) An AliEM post from 2013: "Pediatric febrile seizures: when do I need to do an LP?"

OPTIONAL: A good, solid, Steve Carrol EM Basic Review on Febrile Seizures. 30 minute podcast with show notes available for download.

b) Neonatal Seizures , from PEM Morsels 

 

7) Segue from peds to OB: Eclampsia - a quick bullet point review from LITFL that hits all the main points to remember. (Except, somebody help me: what are GTN and SNP? I'm drawing a blank. At least they're very far down the list...) TWO KEY WORDS TO ASSOCIATE: peripartum, and magnesium. (You won't forget the mag, but don't forget that it can happen postpartum! One-third!)

 

8) Just to squeeze it in, because the boards love it: isoniazid induced seizures, a quick case report review blurb from The Poison Review. Bottom line: I say isoniazid, you say what? ("Pyridoxine!" Yes! Good job.)

 

THE OPTIONAL EXTRAS:

1) Mallory's Hope: a different kind of EM:RAP podcast (November 2014)--the story of a girl with intractable epilepsy, and the lengths her emergency physician father goes to to find a treatment that might help her. 

2) Seizure alert dogs fascinate me. (How do they do it?! And how do the trainers do it? My dog is not this smart. Or maybe it's his trainer's fault--that would be me...)  A brief NYT article on the subject.

3) Ten facts about neurocysticercosis, from the World Health Organization. A common cause of seizures worldwide. 

That's it! Brown residents, remember you have to finish the module in Canvas to receive asynchronous credit.