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The Technique of MMECT
Published in Barry M. Maletzky, C. Conrad Carter, James L. Fling, Multiple-Monitored Electroconvulsive Therapy, 2019
The purpose of inducing unconsciousness in the MMECT patient is to reduce apprehension just before the muscle-blocking agent and the electric stimulus are applied. It is often said, however, that once a seizure is induced the patient would forget everything that had occured just beforehand, thus making anesthesia unnecessary. Are we therefore employing anesthetic agents to make ourselves, not our patients, more comfortable? Probably not; most practitioners performing MMECT, especially unilaterally, have experienced many patients who recall everything that has occurred up to falling asleep. Thus anesthesia is always given before the first seizure. It is not usually needed thereafter for, even though several seizures will be administered, after the first one the postictal state itself provides unconsciousness. Each MMECT session, during which three to five seizures are usually induced, can last from 15 to 45 min, more than adequate for the complete metabolic breakdown of the brief-acting anesthetic. Patients will usually awaken between 15 to 60 min after the last seizure. We have never witnessed a patient awaken prematurely.
Seizures
Published in Lauren A. Plante, Expecting Trouble, 2018
The postictal state is a period of transition back to normal awareness and function lasting several minutes to hours or even days. Confusion, decreased alertness, and focal neurological deficits are typical and should gradually improve. Weakness, called postictal paresis or Todd’s paralysis, is present in approximately 13.4% of patients and may last hours to days (37). Other postictal symptoms may include transient aphasia, amaurosis, hemi anopsia, sensory loss, psychosis, and aggression. Hospitalization is not necessary if the neurological exam is normal and mental status has returned to baseline. Nonetheless, admission is common in pregnant women with new-onset seizures.
Posttraumatic epilepsy and neurorehabilitation
Published in Mark J. Ashley, David A. Hovda, Traumatic Brain Injury, 2017
Theresa D. Hernández, Sudha S. Tallavajhula, Kristina T. Legget, Paul M. Levisohn
During typical focal seizures with dyscognitive phenomena (previously called complex partial seizures), the patient will often stare and become nonresponsive or poorly responsive to commands. Automatisms frequently occur and take the form of lip smacking and swallowing or chewing (oral-alimentary automatisms) and fidgeting with objects. Although the patient may spontaneously speak or seem to respond to commands, the language is inappropriate to the situation. The patient may affirm or disagree when questioned but, generally, gives little more than simple responses and does not follow complex commands. Generally, combativeness occurs only when the person is restrained. Thus, when directed aggression occurs, such as seeking out and striking a staff member, the episode most likely is a conscious act and not the result of a seizure. Thereafter, there is often a several-minute period of confusion and disorientation, which represents the postictal state. The patient will often feel tired or exhausted and will frequently go to sleep. When present, a history of postictal confusion and lethargy often helps to identify episodes as seizures as they generally do not occur or are brief with spells of other etiologies. Amnesia for the event is often noted in patients with focal seizures affecting the memory networks, particularly the temporal lobes. Seizures emanating from the frontal lobes are often brief and may be confused with nonepileptic events due to the bizarre nature of the seizures reported, occasionally without impaired consciousness and without a period of postictal mental change.
Reduced-dose intramuscular ketamine for severe agitation in an academic emergency department
Published in Clinical Toxicology, 2020
Michael E. O’Brien, Lanting Fuh, Ali S. Raja, Benjamin A. White, Brian J. Yun, Bryan D. Hayes
Fifteen patients met the inclusion criteria (Table 1). Twelve (80%) were male with a median age of 33 years and median weight of 75 kg. Agitation was controlled in 13 of 15 patients (87%) following a single dose of reduced-dose ketamine (Table 2). One patient was noted, via nursing documentation, to not be sedated and was administered haloperidol and midazolam within 25 min (study ID 1). The other patient received lorazepam 24 mg IV and haloperidol 5 mg IV, then both doses of IM ketamine 2 mg/kg (total 4 mg/kg), followed by lorazepam 8 mg IV and a dexmedetomidine infusion. He was ultimately intubated due to refractory agitation (study ID 13). The etiology of this patient’s agitation was not fully established, but was likely a combination of cocaine use, heroin and alcohol withdrawal, and a postictal state secondary to a suspected alcohol withdrawal seizure. The median total dose was 157.5 mg (IQR 150–200) and the median weight-based dose was 2 mg/kg (IQR 1.9–2.1). One patient received 500 mg (6.64 mg/kg) IM ketamine in a single dose which deviated from our guideline but was still included in this analysis. One patient had a depressed respiratory drive with a lowest recorded respiratory rate of 8 breaths per minute. This patient had a history of cerebral palsy and presented to the ED for cough and hypoxia. Ketamine was used to facilitate placement of an IV line and a chest radiograph as the patient was uncooperative and agitated. No further adverse effects were noted in any patients and we found no instances of apnea or intubation due to over sedation.
Posterior reversible encephalopathy syndrome possibly induced by pemetrexed maintenance therapy for lung cancer: a case report and literature review
Published in Acta Clinica Belgica, 2018
Gert-Jan Smets, Tine Loyson, Wim Van Paesschen, Philippe Demaerel, Kristiaan Nackaerts
Twenty-eight hours after the first administration of pemetrexed (500 mg/m²) maintenance therapy, the patient was admitted at our hospital with a history of involuntary shaking of her left arm followed by unconsciousness, suspected to be a seizure. This seizure was generalised, tonic clonic in nature and lasted for a few minutes. Her unconsciousness lasted for 5 min and was followed by a postictal state of 30 min. She reported a dull pancranial headache, memory and attention disorder and reduced visual acuity for 2 weeks prior to the seizure. Paracetamol could not relieve headache. She had no history of either migraine or epilepsy. There was no tongue bite nor urinary incontinence. No evidence of focal neurological deficit or meningeal signs were discovered through neurological examination. At admission, she had a blood pressure of 167/132 mm Hg with a regular cardiac pulse of 80 beats per minute, a normal oxygen saturation of 95.5% and a normal body temperature of 37.3 °C.
Flibanserin toxicity in a toddler following ingestion
Published in Clinical Toxicology, 2018
Nicholas Granzella, Betty C. Chen, Geoffrey S. Baird, Matthew Valento
Upon arrival to the ED, it was noted that the patient was not blinking his eyes and did not respond to painful stimuli. Initial vital signs were: blood pressure, 111/61 mmHg; pulse rate, 91 beats/minute; respiratory rate, 22 breaths/min; temperature, 37.4 °C; and room air oxygen saturation, 99%. A point-of-care glucose was 90 mg/dL. Physical examination was notable for dilated and sluggish pupils, normal skin, occasional facial twitching, absence of clonus, and absence of hyperreflexia. His unresponsiveness to painful stimuli and transient facial twitching was concerning for seizure-like activity which resolved after administration of lorazepam 1.5 mg intravenously within 15 min of arrival in the ED. He subsequently responded to painful stimuli and was felt to be in a postictal state.