Disclosures: Derek H. Bui, DO: No financial relationships or conflicts of interest

Case Diagnosis: Catatonia after anoxic brain injury

Case Description or Program Description: A 25-year-old female found unconscious and covered with vomitus suffered an anoxic brain injury, likely due to cardiopulmonary arrest secondary to cocaine overdose. Hospitalization complicated by agitation and pain prior to acute rehabilitation. Upon admission, patient was sedated and difficult to arouse secondary to polypharmacy; olanzapine 10mg qAM, quetiapine 50mg qAM and 100mg qHS, valproic acid 750mg BID, baclofen 10mg TID, diazepam 5mg QID and methadone 5mg TID. Antipsychotics were discontinued and alertness improved. However, patient demonstrated decreased verbal output, oral intake, and psychomotor retardation during diazepam taper. Diazepam 5mg BID was cautiously reinitiated with subtle improvement. Psychiatry was consulted for possible catatonia and recommended lorazepam 1mg IV challenge.

Setting: Acute rehabilitation

Assessment/Results: A diagnosis of catatonia was made given symptoms of mutism as well as staring, psychomotor retardation, decreased oral intake, and cog-wheeling rigidity with immediate improvement after an IV lorazepam challenge. Catatonia was treated with 4mg lorazepam PO QID. Subsequently, patient demonstrated significant cognitive and functional improvement.

Discussion (relevance): Anti-psychotics, anti-convulsants, anti-spasmodics, opioids, and benzodiazepines may decrease consciousness and consequently inhibit neuro-recovery in brain injured patients. It is conventional practice to decrease or discontinue these classes of medications as soon as possible during brain injury recovery. However, in this case, use of benzodiazepines provided a paradoxical and essential stimulating effect.

Conclusions: Catatonia is a rare consequence of brain injury and an under-recognized manifestation as its clinical presentation may overlap with the primary brain injury itself. However, this case addresses the importance of recognizing this unique entity. Use of benzodiazepines, in the appropriate population, has been supported and may completely change the outcome of a brain injured patient. Furthermore, recognizing catatonia as a potential sequela may prevent use of precipitating agents such as antipsychotics and aid in the diagnosis of rare conditions such as delayed post hypoxic leukoencephalopathy.

Level of Evidence: Level V

« Back to AAPM&R Annual Assembly 2022

PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/paradoxical-use-of-benzodiazepines-in-anoxic-brain-injury/