Albert Einstein Medical Center, 5501 Old York Rd., Philadelphia, PA 19141, USA.
Am J Psychiatry. 2010 Feb;167(2):127-32. doi: 10.1176/appi.ajp.2009.09050703.
Acute catatonia in an adolescent or young adult can present complex clinical challenges. Prominent issues include those involving diagnosis, timely and effective treatment, and diminished capacity to provide consent. The authors describe a 19-year-old woman presenting initially with manic excitement followed by a lengthy period of mutism, immobility, and food and fluid refusal. Elevated temperature, an elevated creatine phosphokinase level, and autonomic dysfunction led to consideration of a malignant catatonic syndrome. The patient manifested rigidity accompanied by posturing and waxy flexibility. Neurologic, medical, and laboratory evaluations failed to identify an organic cause for the likely catatonia. Treatment with amantadine, bromocriptine, and lorazepam was unsuccessful. ECT was deemed appropriate but required emergency guardianship because of the patient's inability to provide consent. At the initial ECT session, the elicited seizure was followed by an episode of torsade de pointes requiring immediate cardioversion. In reviewing the ECT complication, it appeared that muscle damage due to catatonic immobility led to acute hyperkalemia with the administration of succinylcholine. Discussions were held with the patient's guardian outlining the clinical issues and the risks of additional ECT. The patient responded to eight subsequent ECT sessions administered with rocuronium, a nondepolarizing muscle relaxant. The authors provide a brief review of the diagnosis and treatment of catatonia and address issues surrounding ECT, cardiac effects, use of muscle relaxants, and the consent process.
青少年或年轻成人的急性紧张症可能会带来复杂的临床挑战。突出的问题包括诊断、及时有效的治疗以及同意能力下降。作者描述了一位 19 岁女性，最初表现为躁狂兴奋，随后长时间出现缄默、不动、拒绝进食和饮水。体温升高、肌酸磷酸激酶水平升高和自主神经功能障碍导致考虑恶性紧张症综合征。患者表现出僵硬，伴有姿势和蜡样灵活性。神经、医学和实验室评估未能确定可能的紧张症的器质性原因。给予金刚烷胺、溴隐亭和劳拉西泮治疗无效。由于患者无法同意，认为电休克治疗是合适的，但需要紧急监护。在最初的电休克治疗期间，诱发的抽搐后出现尖端扭转型室性心动过速，需要立即进行电复律。在回顾电休克治疗的并发症时，似乎由于紧张性不动导致的肌肉损伤导致给予琥珀酰胆碱时出现急性高钾血症。与患者的监护人进行了讨论，概述了临床问题和额外电休克治疗的风险。患者对随后进行的 8 次电休克治疗有反应，使用的是罗库溴铵，一种非去极化肌肉松弛剂。作者简要回顾了紧张症的诊断和治疗，并讨论了电休克治疗、心脏效应、肌肉松弛剂的使用以及同意程序等问题。
