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A Tale of Two Catatonic States
- Harleen Kaur Birgi, Geoff Lawrence-Smith, Simon Kirwin
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S119
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Aims
Catatonia is a psychomotor state characterised by a multitude of clinical signs such as abnormal movements, mutism and withdrawal. This condition is usually associated with medical and psychiatric aetiologies with potential of being life-threatening. It is usually managed with benzodiazepines, the commonest being lorazepam. In this piece of work, we would like to focus on the principles of care that should be considered whilst managing such presentations.
MethodsCase 1- 71, male with diagnosis of paranoid schizophrenia was brought to Emergency department (ED) via ambulance, as he was found ‘unresponsive’ in care home. On arrival, he was alert with GCS 11/15 and was observed to be mute, ‘gesturing’ and making purposeless movements. Following our assessment, he was administered 0.5mg of lorazepam whilst in resuscitation bay. Subsequently, he started making sounds and was given another dose of 0.5mg lorazepam. He then vocalised his thoughts and we established that his mental state had relapsed and he was harbouring paranoid delusions.
Case 2- 18, male with no prior psychiatric history was brought to ED by his parents following 3 day history of being mute, not ‘responding’, not eating or drinking and insomnia. On arrival, he was alert, pacing in the room, however remained mute. Following our assessment, he was given a 2 mg dose of lorazepam whilst in resuscitation bay as the initial 1mg showed minimal response. On later review, he was smiling, conversant and co-operative, thus allowing assessment of his unmasked mental state which was suggestive of first episode psychosis.
Following few hours, both patients reverted back to their original catatonic state.
ResultsLorazepam can be used as a diagnostic measure in conjunction to a therapeutic intervention. A positive Lorazepam Challenge test confirms the diagnosis of catatonia. It must be borne in mind that Lorazepam is only used as a temporary holding measure to assess patient's unmasked mental state and they would need further monitoring and interventions to treat the underlying cause.
ConclusionLorazepam Challenge test can be safely used as an assessment technique for patients presenting in acute catatonia. This should be conducted in closely monitored environments namely, resuscitation bay, HDU or ITU with appropriate support and ongoing liaison with psychiatry team. Treating teams should be mindful of various patient characteristics including age, past treatment with benzodiazepines, psychiatric history to inform dose adjustments as necessary.
Disclaimer: Unable to obtain patient consent due to unstable mental state but ensured minimal patient identifiable data included.
Have You Seen the NEWS Today? - a QI Project
- Harleen Kaur Birgi
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, pp. S87-S88
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Aims
The main focus of this QIP was to improve the documentation of NEWS (National early warning scores) and subsequent escalation as appropriate in an Old Age Psychiatric Ward setting. This would in turn lead to improved Physical health outcomes, especially in the COVID-19 pandemic.
MethodsThe NEWS chart is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, when patients present to, or are being monitored in hospital. This will ensure that patients who are deteriorating, or at risk of deteriorating, will have a timely initial assessment. This should supplement clinical judgement in assessing the patient's condition.
Early detection and escalation of deteriorating NEWS leads to improved patient outcomes and referral to the appropriate specialties, for subsequent management.
The initial phase of the QIP comprised of retrospective data collection surrounding the recognition and documentation of NEWS on an 18-bedded Old age Psychiatric ward. This period spanned the 2nd wave of the pandemic, from November- December.
Potential interventions were implemented in the form of raising NEWS awareness by educating nursing staff via teaching sessions, displaying posters all over the ward and nursing station. Team also reviewed all NEWS charts everyday during ward management rounds which served as a daily reminder for the staff measuring the observations.
NEWS of & greater than 3 was defined as the threshold for escalation.
Following change implementation, data were collected to capture the progress made over a month.
ResultsAnalysis of data pre and post- interventions displayed a significant improvement in escalation of unwell patients from 26% to 60%.
ConclusionImproved outcomes and early detection of potentially deteriorating patients, leading to early transfer of patients to an Acute Medical setting and better overall management.
Raised awareness and understanding of physical health management in Mental Health nurses.
The QIP was presented at the Trust QI Forum meeting and was met by and overwhelmingly positive response. In order to enhance NEWS recording an electronic format is now being adapted. There is also a consideration around providing regular NEWS teaching sessions to all inpatient staff across the trust.