Funtabulously Frivolous Friday Five 357

Catatonia

In 2013, the DSM-5 removed catatonia as a subtype of schizophrenia and listed it as a feature of several psychiatric and medical conditions. In 2022, the ICD-11 recognised catatonia as an independent diagnostic entity, on par with mood disorders and schizophrenia.  Catatonia may be difficult to distinguish from delirium, a separate but common process encountered in EDs. Unlike catatonia, delirium is defined by fluctuating levels of attention and cognition. 

The mechanism behind it remains poorly understood. Catatonic signs may emerge rapidly, reaching a maximum level within hours in acute catatonia, or may develop slowly over days or weeks. Catatonic episodes may recur periodically, or they may persist for years, as seen in some patients with schizophrenia spectrum disorders or neurodevelopmental disorders, including autism. Catatonia can be recognized by many diagnostic signs, including:

• Staring
• Stupor*
• Mutism*
• Posturing & Catalepsy
• Rigidity
• Echolalia/Echopraxia.
• Waxy flexibility: resistance to provider’s positioning

(* most common presentations of catatonia in EDs).

The “Lorazepam Challenge” comprises the administration of 1 to 2 mg of lorazepam and can be found to be both diagnostic and therapeutic for patients with catatonia. Patients ideally become more mobile if previously stuporous, verbal if previously mute, or resume oral intake if previously rejecting. If successful, lorazepam can be continued or increased to up to 16 mg daily.

This makes sense. If you managed to hunt a big meal, you couldn’t eat it all, but by sharing the spoils, you helped support the community and ensured others would share when times were tough for you. This ‘other-focused’ mentality meant that more compassionate humans were the ones who survived and passed on their genes.

Reference:

• Seetharaman A, Chauhan VS, Adhvaryu A, Prakash J. Lorazepam challenge test: A unique clinical response in catatonia. Ind Psychiatry J. 2021 Oct;30(Suppl 1):S235-S236.
• Heckers S, Walther S. Catatonia. N Engl J Med. 2023 Nov 9;389(19):1797-1802.
• Smith C. Catatonia – What You Need to Know. Journal feed

A soft bandage only.

Probably one to discuss with your orthopaedic team before instigating… but here is the evidence:

Okay, so there are no points for recognizing the above fracture is a distal radial buckle (or torus) fracture. These are incomplete fractures of the shaft of a long bone characterised by a bulging of the cortex resulting from trabecular compression secondary to axial loading along the long axis of the bone. They are most commonly seen in children involving the distal radial metaphysis.

Until recently, the standard management for these injuries had been back slab or splint. However, Perry et al. in The Lancet, July 2022, compared standard practice to the application of soft bandage only and no outpatient follow-up.

Perry et al. found equivalence in pain at three days in the bandage group to the rigid immobilisation group, with no between-group differences in pain or function during the six weeks of follow-up.

Reference:

• Perry DC, Achten J, Knight R, Appelbe D, Dutton SJ, Dritsaki M, Mason JM, Roland DT, Messahel S, Widnall J, Costa ML; FORCE Collaborators in collaboration with PERUKI. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet. 2022 Jul 2;400(10345):39-47
• Fractures – Distal forearm or wrist. PCH Emergency Department.

Florence Nightingale (1820-1910)

In an era when communicable diseases were thought to be inevitable and infectious causes nowhere near as well understood as they are today, Nightingale forged new information-gathering techniques and consistency in data recording in addition to her better-known work as a nurse in the Crimean War 1853-1856. 

She is credited with reducing the mortality rate in Scutari, the military hospital where she led a team of voluntary nurses, from forty percent to two percent. This was largely because, at her insistent petitioning, the British government sent out a sanitary commission that cleared a broken sewer contaminating the water supply and improved ventilation in the squalid wards. 

It is as criminal to have a mortality of 17, 19, and 20 per thousand in the Line, Artillery and Guards, when that in civil life is only 11 per 1,000, as it would be to take 1,100 men out upon Salisbury Plain and shoot them

Nightingale 1856

While Nightingale is best known worldwide for revolutionising nursing and healthcare through her ongoing post war campaigning for health reform, her far-reaching recommendations were based on genuinely impressive statistical work and popularised through pioneering data visualisation.

Nightingale worked closely with medical statistician William Farr (1807-1883) to create a series of analytic arguments for better sanitation in the British Army. The most famous graphics from their collaboration are three comparative polar-area diagrams known today as the Nightingale rose. These were originally printed in a confidential 1858 report presented to the Secretary of State for War.

The ‘Rose Diagram’, titled the ‘Diagram of the Causes of Mortality in the Army of the East’, showed that epidemic disease was responsible for more British deaths in the course of the Crimean War than battlefield wounds, AND could be controlled by a variety of factors including nutrition, ventilation, and shelter. The graphic, which Nightingale used as a way to explain complex statistics, simply, clearly, and persuasively, was used to influence the patriarchy originally in the British military and later in application to public hospitals and the broader uptake of sanitation in healthcare. 

Florence became the first female member of the Royal Statistical Society, joining the Society (then the London Statistical Society) two years after her return from the Crimean War. She remained a member until her death more than 50 years later.

Reference:

• Nightingale F. Notes on matters affecting the health, efficiency, and hospital administration of the British Army: founded chiefly on the experience of the late war. 1858
• Andrews RJ. Florence Nightingale is a Design Hero. 2019
• Nightingale 2020: The bicentenary of our first female fellow. Royal statistical society

Caffeine.

The average cup of coffee contains anywhere from 70-140mg of caffeine, green tea 20-45mg, white teas anywhere from 6-60mg caffeine. Old school No-Doz (or similar) tablets contain 100mg caffeine, but many of the products available over the counter and online as performance enhancing supplements, contain up to 200mg of caffeine per tablet/capsule.

Caffeine (1,3,7-Trimethyxanthine) is an adenosine receptor antagonist and phosphodiesterase antagonist. Massive caffeine overdose can cause life-threatening seizures and arrhythmias, although severe caffeine toxicity is rare unless in massive ingestion:

• >30mg/kg: mild to moderate toxicity
• >100mg/kg: severe toxicity
• >150mg/kg: life-threatening toxicity. 

Caffeine reaches its peak plasmatic concentration in 30 to 60 minutes, whereas its half-life is reported to be from two to 12 hours due to interindividual variability and total dose taken. Intoxication may present with mild symptoms like headache, nausea, vomiting, tachycardia, anxiety, insomnia, dizziness, or irritability. Investigations may show hyperglycaemia, hypokalaemia, rhabdomyolysis, renal failure, and hyperlactataemia.

Aggressive supportive care is the mainstay of management (from Austin Tox Guidelines):

• Decontamination: Offer activated charcoal 50 g if < 2 hours post ingestion
• Fluid & Electrolytes: 
  • IV fluid replacement if dehydrated from vomiting or as initial treatment of hypotension.
  • If ↓K, replace with caution. Aim K+ 3.0-3.5 mmol/L as ↓K+ is due to intracellular shift & not K+ loss.
  • Significant potential for rebound ↑K+.
• Seizures:
  • Diazepam 5 mg IV every 5 minutes as necessary.
• Agitation:
  • Diazepam 2.5-5 mg IV q10 minutes or 5–10 mg PO q30 minutes
• Arrhythmias (SVT, VT, or refractory VF):
  • Esmolol (500 mcg/kg IV over 1 minute, followed by 25 – 200 mcg/kg/min infusion as required)
  • Adenosine may also be used for SVT but higher doses may be required.
• Enhanced Elimination:
  • Multi-dose Activated Charcoal (MDAC, see separate guideline) (25g every 2 hours): consider in ingestions > 50mg/kg.
  • Consider haemodialysis if severe refractory toxicity.

Reference:

• Pina Cabral J, Sousa DL, Carvalho C, Girao A, Pacheco Mendes A, Pina R. Caffeine Intoxication: Unregulated, Over-the-Counter Sale of Potentially Deadly Supplements. Cureus. 2022 Jan 9;14(1):e21045