J Emerg Med
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Hypermagnesemia is an often overlooked electrolyte abnormality that has a myriad of presenting symptoms. It has been observed after both accidental and intentional ingestions of magnesium-containing compounds, and as in the case presented, Epsom salts, which are primarily magnesium sulfate. ⋯ A 56-year-old man presented to the emergency department reporting weakness after an ingestion of Epsom salts used as a laxative and was found to be bradycardic and hypotensive. He subsequently developed altered mental status and respiratory depression necessitating intubation. His magnesium level was found to be > 3.91 mmol/L (> 9.5 mg/dL). He was given multiple doses of calcium gluconate and generous i.v. fluids with furosemide, with minimal improvement. However, his magnesium level corrected rapidly after initiation of dialysis, and 3 days later he was discharged home in good condition with normal neurologic function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Keeping a high level of suspicion for, and quickly recognizing, hypermagnesemia allows for prompt initiation of treatment, which can avoid significant hemodynamic or respiratory compromise. Mainstays of treatment are i.v. calcium and i.v. fluids. Loop diuretics may be given as an adjunct as well. Dialysis should be considered in cases of severe hypermagnesemia because it results in rapid correction of magnesium levels.
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Ketamine's application in psychiatry have expanded, but it appears never to have been previously used to diagnose and treat patients with catatonia-like syndrome that occasionally present to emergency departments. ⋯ A 23-year-old male was observed to suddenly stop talking. His ED GCS was 8 and had normal vital signs. While verbally unresponsive, he refused to open his eyes, demonstrated waxy flexibility of his arms, but the balance of his physical, neurological, and laboratory exams were normal. Strongly suspecting a catatonic state, they needed to rapidly confirm that diagnosis or begin evaluating him for potentially life-threatening non-psychiatric illnesses. Lacking other diagnostic modalities, they administered low-dose ketamine boluses. Ketamine 25 mg (1 mL) was diluted in 9 mL NS (2.5 mg/mL). Based on similar protocols, 1 mL of the solution (0.03 mg/Kg) was given intravenously every few minutes. After 12.5 mg ketamine, he was conscious and verbal. Subsequent history confirmed a prior episode requiring an extensive, non-productive medical evaluation. Psychiatry later confirmed the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with catatonia-like states pose a difficult diagnostic and therapeutic dilemma. Multiple interventions have been used with varying success. Optimal interventions provide a rapid resolution (or demonstrate that a psychiatric cause is not likely), be safe, encompass few contraindications, and be familiar to the clinician. In our patient, subanesthetic doses of ketamine fulfilled these criteria and successfully resolved the condition. If shown effective in other cases, ketamine would be a valuable addition to our psychiatric armamentarium.