Depressed Mental Status Research Articles

Case Report

Case Report

Accidental Ingestion of Venlafaxine in a 9 Month Old Infant

Venlafaxine is a serotonin/norepinephrine reuptake inhibitor approved for adults with depressive, panic, and anxiety disorders. The safety and efficacy of venlafaxine has not yet been adequately established in pediatric patients to allow approval although studies have been reported in children and adolescents with primarily attention-deficit hyperactivity disorder and depression. The intentional or unintentional use of venlafaxine in patients less than 3 years of age has not been extensively reported. OBJECTIVE: To report the adverse effects following the probable accidental ingestion of venlafaxine in a 9-month-old infant. CASE SUMMARY: The infant presented to the emergency department about 7 hours after a presumed ingestion of a single 150 mg venlafaxine extended-release capsule. His mother and grandmother described him as having a “drugged look”, trembling, shaking, pill-rolling with his tongue, dilated pupils, and other odd behaviors. Upon presentation to the emergency room, he was sedate, had dilated pupils, and had depressed mental status. His urine was positive for phencyclidine (PCP), but a confirmatory test could not be done due to mishandling of the specimen. He was admitted and observed throughout the night. He was acting and eating normally the following morning and was subsequently discharged in stable condition. CONCLUSIONS: There is minimal information regarding venlafaxine toxicity in infants and children but accidental ingestion may cause a variety of serotonergic, anticholinergic, and neuromuscular adverse effects, mental status changes, and autonomic instability. Supportive care is a reasonable treatment when symptoms are not severe.

Part 12: Cardiac Arrest in Special Situations

This section of the 2010 AHA Guidelines for CPR and ECC addresses cardiac arrest in situations that require special treatments or procedures beyond those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). We have included 15 specific cardiac arrest situations. The first several sections discuss cardiac arrest associated with internal physiological or metabolic conditions, such as asthma (12.1), anaphylaxis (12.2), pregnancy (12.3), morbid obesity (12.4), pulmonary embolism (PE) (12.5), and electrolyte imbalance (12.6). The next several sections relate to resuscitation and treatment of cardiac arrest associated with external or environmentally related circumstances, such as ingestion of toxic substances (12.7), trauma (12.8), accidental hypothermia (12.9), avalanche (12.10), drowning (12.11), and electric shock/lightning strikes (12.12). The last 3 sections review management of cardiac arrest that may occur during special situations affecting the heart, including percutaneous coronary intervention (PCI) (12.13), cardiac tamponade (12.14), and cardiac surgery (12.15). Asthma is responsible for more than 2 million visits to the emergency department (ED) in the United States each year, with 1 in 4 patients requiring admission to a hospital.1 Annually there are 5,000 to 6,000 asthma-related deaths in the United States, many occurring in the prehospital setting.2 Severe asthma accounts for approximately 2% to 20% of admissions to intensive care units, with up to one third of these patients requiring intubation and mechanical ventilation.3 This section focuses on the evaluation and treatment of patients with near-fatal asthma. Several consensus groups have developed excellent guidelines for the management of asthma that are available on the World Wide Web: ### Pathophysiology The pathophysiology of asthma consists of 3 key abnormalities: Complications of severe asthma, such as tension pneumothorax, lobar atelectasis, pneumonia, and pulmonary edema, can contribute to fatalities. Severe asthma exacerbations are commonly associated with …

Part 14: Pediatric Advanced Life Support

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1 Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below). Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9 It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

Cevimeline (Evoxac ®) Overdose

Cevimeline (Evoxac ®) is an oral muscarinic agent that has been recently approved for the treatment of xerostomia in the setting of Sjogren's syndrome. Its toxicity in overdose has not been reported in the medical literature to date. We report a previously healthy patient who intentionally ingested approximately 10 mg/kg of cevimeline and presented with symptoms of muscarinic excess and mental status depression. The patient recovered uneventfully after receiving activated charcoal and supportive care. This report describes the first documented cevimeline overdose.

Thyroid storm after coronary artery bypass grafting

We describe a 45-year-old woman with thyroid storm developing after urgent coronary artery bypass grafting (CABG). The hallmark clinical features included fever, tachycardia, depressed mental status, and jaundice. Thyroid testing confirmed severe hyperthyroidism caused by Graves disease. The patient was rendered euthyroid after initiation of therapy with methimazole (INN, thiamazole), potassium iodide, and hydrocortisone.

E-029 Symptomatic cerebral vasospasm after trans-sphenoidal resection of pituitary macroadenomas

IntroductionDelayed ischemic events are recognized complications following aneurysmal subarachnoid hemorrhage (SAH). Delayed cerebral vasospasm may also occur following traumatic SAH or craniotomy for skull base tumors. The occurrence of a...

Necrotic arm lesions in an intravenous drug user

A 62-year-old woman with a history of long-term intravenous drug use and chronic Hepatitis C virus infection was admitted to another hospital unresponsive with profound hypotension. Her symptoms were attributed to a drug overdose leading to a depressed mental status, and possibly septic shock with aspiration pneumonia. She was placed on mechanical ventilation, and treated with vasopressors, high-dose corticosteroids and several broad-spectrum antibiotics. Blood and urine cultures were negative. When she failed to improve after 1 week she was transferred to the intensive care unit at our institution. On transfer, she was unresponsive, intubated, on mechanical ventilation, and hypotensive on vasopressors. We also noted that she had multiple ulcerated skin lesions on both upper extremities (Fig. 1). The lesions involved the dorsum of both hands and wrists, medial aspects of both arms, and the left antecubital fossa. The edges of the lesions were necrotic and the base was macerated. The WBC count was 22,500 mm with 85% neutrophils and 7% band forms. The creatinine was 3 mg/dL. An acute renal failure was attributed to acute tubular necrosis. HIV testing was negative. The CT scans of the chest, abdomen, pelvis, and MRI of the head were unrevealing, and a lumbar puncture was unremarkable. A skin biopsy of the leading edge of the ulcer was performed.

Prospective comparative assessment of buprenorphine overdose with heroin and methadone: Clinical characteristics and response to antidotal treatment

Buprenorphine is a partial opioid agonist with a “ceiling effect” for respiratory depression. Despite this, it has been associated with severe overdoses. Conflicting data exist regarding its response in overdose to naloxone. We compared clinical overdose characteristics of buprenorphine with heroin and methadone and assessed responses to naloxone and flumazenil. Patients admitted to two intensive care units with severe opioid overdoses were enrolled into this 4-year prospective study. Urine and blood toxicological screening were performed to identify overdoses involving predominantly buprenorphine, heroin, or methadone. Eighty-four patients with heroin ( n = 26), buprenorphine ( n = 39), or methadone ( n = 19) overdoses were analyzed. In the buprenorphine group, sedative drug coingestions were frequent (95%), whereas in the methadone group, suicide attempts were significantly more often reported ( p = .0007). Buprenorphine overdose induced an opioid syndrome not differing significantly from heroin and methadone in mental status (as measured by Glasgow Coma Score) or arterial blood gases. Mental status depression was not reversed in buprenorphine overdoses with naloxone (0.4–0.8 mg) but did improve with flumazenil (0.2–1 mg) if benzodiazepines were coingested. In conclusion, buprenorphine overdose causes an opioid syndrome clinically indistinguishable from heroin and methadone. Although mental status and respiratory depression are often unresponsive to low-dose naloxone, flumazenil may be effective in buprenorphine overdoses involving benzodiazepines.

Anticonvulsant Use and Outcomes After Intracerebral Hemorrhage

There are few data on the effectiveness and side effects of antiepileptic drug therapy after intracerebral hemorrhage. We tested the hypothesis that antiepileptic drug use is associated with more complications and worse outcome after intracerebral hemorrhage. We prospectively enrolled 98 patients with intracerebral hemorrhage and recorded antiepileptic drug use as either prophylactic or therapeutic along with clinical characteristics. Antiepileptic drug administration and free phenytoin serum levels were retrieved from the electronic medical records. Patients with depressed mental status underwent continuous electroencephalographic monitoring. Outcomes were measured with the National Institutes of Health Stroke Scale and modified Rankin Scale at 14 days or discharge and the modified Rankin Scale at 28 days and 3 months. We constructed logistic regression models for poor outcome at 3 months with a forward conditional model. Seven (7%) patients had a clinical seizure, 5 on the day of intracerebral hemorrhage. Phenytoin was associated with more fever (P=0.03), worse National Institutes of Health Stroke Scale at 14 days (23 [9 to 42] versus 11 [4 to 23], P=0.003), and worse modified Rankin Scale at 14 days, 28 days, and 3 months. In a forward conditional logistic regression model, phenytoin prophylaxis was associated with an increased risk of poor outcome (OR, 9.8; 1.4 to 68.6; P=0.02), entering after admission National Institutes of Health Stroke Scale and age. Excluding patients with a seizure did not change the results. Levetiracetam was not associated with demographics, seizures, complications, or outcomes. Phenytoin was associated with more fever and worse outcomes after intracerebral hemorrhage.

Tracheobronchial Foreign Body Aspiration in Adults

Tracheobronchial foreign body (TFB) aspiration is rare in adults, although incidence rates increase with advancing age. Risk factors for TFB aspiration in adults are a depressed mental status or impairment in the swallowing reflex. Symptoms associated with TFB aspiration may range from acute asphyxiation with or without complete airway obstruction, to cough, dyspnea, choking, or fever. In adults, many other medical conditions mimic breathing abnormalities similar to those associated with TFB aspiration. If the history is not suggestive, then only a high index of suspicion can ensure proper diagnosis and timely removal of the foreign body. Initial treatment is airway support. Radiographic imaging may assist in localizing the foreign body. Bronchoscopic removal of the foreign body is necessary to avoid long-term sequelae. Flexible bronchoscopy is effective both in the diagnosis and removal of foreign bodies.

パロキセチン内服中に低ナトリウム血症を来し，SIADHと診断された食思不振の高齢患者

We report an 82-year old man prescribed paroxetine who had hyponatremia and in whom the syndrome of inappropriate secretion of antidiuretic hormone was diagnosed. He had taken sulpiride for depressed mental status. However, he showed parkinsonism, which was an adverse effect from the treatment of sulpiride. Therefore sulpiride was changed to selective serotonin reuptake inhibitor, paroxetine 10mg daily. His depressed mental status deteriorated after paroxetine treatment started. His depression had not lessened after 12 days, and the dosage was increased to 20mg daily. On the 15th day after starting paroxetine, routine laboratory tests showed that his serum sodium level was 126 mEq/l. We recognized that his confusion and loss of appetite were symptoms of hyponatremia, rather than of worsening depression. Laboratory data revealed hyponatremia, low serum osmolarity (242 mOsm/kg) with a relatively high level of serum antidiuretic hormone, and concentrated urine (439 mOsm/kg). We diagnosed the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), associated with paroxetine. The dosage of paroxetine was reduced gradually and the serum sodium level returned to normal on day 2 after medication ceased completely. Paroxetine produces fewer adverse effects than other types of antidepressants. However, its use can be associated with inappropriate secretion of antidiuretic hormone in the body and may lead to SIADH, which is characterized by hyponatremia, a potentially fatal condition that is typically asymptomatic until it becomes severe. SIADH is more likely in some populations, including the elderly. Serum sodium levels should be monitored closely, especially in elderly patients.

Variation of the choline signal intensity in the dorsolateral prefrontal cortex of rats exposed to the forced swimming test as detected by in vivo1H MR spectroscopy

Background 1H magnetic resonance spectroscopy (MRS) has documented an increased Cho/Cr ratio in the dorsolateral prefrontal cortex (DLPFC) in major depressive disorder (MDD). The aim of this study was to investigate neurochemical alterations in the left DLPFC, considered a main area of pathogenesis in depression, using rats exposed to the forced swimming test (FST). Materials and methods Twenty-four male rats were used for the MRI and in vivo 1H MRS studies. Rats exposed to the FST to induce a depressed mental status. Using in vivo 1H MRS, the metabolite ratios of the rats with a depressed mental status and the controls, were measured and the values of the two groups were compared. Results The Cho/Cr and Cho/NAA ratios in the DLPFC of the rats with a depressed mental status were significantly higher than that in the controls. Conclusions The present study demonstrates a significantly increased Cho/Cr ratio in the DLPFC of rats with depression compared with controls. This result may suggest an accelerated turnover of membrane without neuronal loss is occurring in the DLPFC of the rats with depression.

Rosenthal Fiber Encephalopathy in a Dog Resembling Alexander Disease in Humans

A young male Bernese mountain dog presented with neurologic abnormalities consisting of nonambulatory tetraparesis, generalized tremors, and depressed mental status. At necropsy only a mild enlargement of the lateral ventricles was seen. The histologic examination revealed the presence of eosinophilic deposits consistent with Rosenthal fibers (RFs) throughout the white matter of the central nervous system. There was also a marked proliferation of abnormally large astrocytes and limited myelin changes. RFs were most prominent in perivascular, subpial, and subependymal areas, where they were perpendicularly located, producing a pallisaded arrangement. Immunohistochemically, RFs were strongly positive for glial fibrillary acidic protein (GFAP), and when they were examined ultrastructurally they appeared as electron-dense amorphous masses located within the processes of astrocytes, most particularly in the perivascular feet. The histologic and immunohistochemical findings of this canine case were consistent with the published neuropathologic descriptions of Alexander disease in humans and in a few dogs, a rare condition that in humans has been shown to be caused by dominant mutations in the GFAP gene.

Adverse Effects in Children After Unintentional Buprenorphine Exposure

Buprenorphine in sublingual formulation was recently introduced to the American market for treatment of opioid dependence. We report a series of 5 toddlers with respiratory and mental-status depression after unintentional buprenorphine exposure. Despite buprenorphine's partial agonist activity and ceiling effect on respiratory depression, all children required hospital admission and either opioid-antagonist therapy or mechanical ventilation. Results of routine urine toxicology screening for opioids were negative in all cases. Confirmatory testing was sent for 1 child and returned with a positive result. The increasing use of buprenorphine as a home-based therapy for opioid addiction in the United States raises public health concerns for the pediatric population.

Detection of Neospora caninum Tachyzoites in Canine Cerebrospinal Fluid

4-year-old female Labrador Retriever was referred to the Veterinary Teaching Hospital of the Autonomous University of Barcelona because of progressive, generalized ataxia and depressed mental status of 5 days’ duration. Before the onset of signs of neurologic dysfunction, the dog had been anorexic, lethargic, and hyperthermic for 7–10 days. The dog had been treated with doxycycline (5 mg/kg of body weight PO q12h) by the referring veterinarian without clinical improvement. During that time, general attitude, condition, and gait had progressively worsened. Over the 12 hours before presentation, the dog experienced a generalized seizure. Routine vaccinations were current, the owners did not report any previous medical history, and the possibility of exposure to toxins was considered unlikely.

Hyperglycemic hyperosmolar nonketotic syndrome

Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) was infrequently diagnosed till recently. Now it is being diagnosed with increasing frequency in obese children with type 2 diabetes mellitus (T2 DM) and its incidence is likely to go up, given global increase in incidence of childhood obesity, increased insulin resistance, and T2 DM. The syndrome is characterized by severe hyperglycemia, a marked increase in serum osmolality and dehydration without accumulation of beta -hydroxybutyric or acetoacetic ketoacids. Significant ketogenesis is restrained by the ability of the pancreas to secrete small amount of insulin. Prolonged phase of osmotic diuresis leads to severe depletion of body water, which excees that of sodium, resulting in hypertonic dehydration. These children, usually obese adolescents with T2 DM, present with signs of severe dehydration and depressed mental status but continue to have increased rather than decreased urine output and are at increased risk of developing rhabdomyolysis and malignant hyperthermia. Emergency treatment is directed at restoration of the intravascular volume, followed by correction of deficits of fluid and electrolyte (Na+, K+, Ca++, Mg++, PO4++), hyperglycemia and serum hyperosmolarity, and a thorough search for conditions that may lead to this metabolic decompensation and their treatment. Use of iso-osomolar isotonic fluid (0.9% saline) until hemodynamic stabilization initially, followed by 0.45% saline with insulin infusion at the rate of 0.1 units/kg/hour, addition of 5% dextrose in fluids and reduction of insulin infusion once the blood glucose is 250 to 300 mg/dl is generally recommended. However, evidence-based guidelines about composition and tonicity of fluids and electrolyte solutions for early resuscitation and rehydration, the rate of infusion-rapid vs slow, and insulin dose-low vs normal, in treatment of HHNS in children are awaited. Careful monitoring of glucose levels and ensuring adequate hydration in patients 'at risk' of HHNS, including those receiving medications that interfere with the secretion or effectiveness of insulin should decrease the risk of HHNS.

Detection of Neospora caninum Tachyzoites in Canine Cerebrospinal Fluid

4-year-old female Labrador Retriever was referred to the Veterinary Teaching Hospital of the Autonomous University of Barcelona because of progressive, generalized ataxia and depressed mental status of 5 days’ duration. Before the onset of signs of neurologic dysfunction, the dog had been anorexic, lethargic, and hyperthermic for 7–10 days. The dog had been treated with doxycycline (5 mg/kg of body weight PO q12h) by the referring veterinarian without clinical improvement. During that time, general attitude, condition, and gait had progressively worsened. Over the 12 hours before presentation, the dog experienced a generalized seizure. Routine vaccinations were current, the owners did not report any previous medical history, and the possibility of exposure to toxins was considered unlikely.

Computed Tomography Versus Plain Radiography to Screen for Cervical Spine Injury: A Meta-Analysis

To compare the test performance of plain radiography and computed tomography (CT) in the detection of patients with cervical spine injuries following blunt traumatic events among those patients determined to require screening radiography. We conducted a MEDLINE search for articles published from January 1995 through June 2004, manually reviewed bibliographies, and hand searched four journals. Studies were included if they contained data on the performance of both plain radiography and CT in the detection of patients with blunt cervical spine injuries. Both authors screened titles and abstracts identified by the search and seven of the 712 articles met all inclusion criteria. Both authors independently abstracted data from these seven studies and disagreements were resolved by mutual agreement. Patient entry criteria were highly variable for each study and there were no randomized controlled trials. For identifying patients with cervical spine injury, the pooled sensitivity for cervical spine plain radiography was 52% (95% CI 47, 56%) and for CT was 98% (95% CI 96, 99%). The test for heterogeneity suggests that significant differences exist between studies in the measurement of the sensitivity for plain radiography (p = 0.07). Due to limitations of the gold standard tests in each study, a calculation of a combined specificity was not possible. Despite the absence of a randomized controlled trial, ample evidence exists that CT significantly outperforms plain radiography as a screening test for patients at very high risk of cervical spine injury and thus CT should be the initial screening test in those patients with a significantly depressed mental status. There is insufficient evidence to suggest that cervical spine CT should replace plain radiography as the initial screening test for less injured patients who are at low risk for cervical spine injury but still require a screening radiographic examination.

A Novel Spongiform Degeneration of the Grey Matter in the Brain of a Kitten

A young female domestic short-hair cat presented with neurological signs consistent with a multifocal encephalic lesion (depressed mental status, head tilt to the right, cervical ventroflexion, head tremors, tetraparesis, conscious propioceptive deficits in all four limbs and visual deficits). No gross lesions were seen at necropsy. On light microscopical examination lesions were found only in the brain and cervical spinal cord. A generalized vacuolation of the grey matter of the brain was observed. Special staining techniques, immunohistochemistry, lectin affinity histochemistry and ultrastructural studies were performed to characterize the lesion; preservation of the white matter and a reactive astrogliosis were demonstrated. Feline retroviruses and PrP sc were not detected. Ultrastructurally, a dilatation of intracytoplasmic membrane-bounded organelles with membrane disruption and dendritic and somatic swelling was found in astrocytes and neurons. The age of the animal and histological changes suggested a novel, possibly congenital, spongiform degeneration of the brain and cervical spinal cord.