Approach to the Critical Patient

Immediate priorities

Airway and breathing assessment

Circulation and autonomic instability

Malignant catatonia recognition

Malignant catatonia features

Key decision points and consult triggers

Urgent psychiatry consultation for all catatonia presentations

Neurology consultation triggers

Critical care consultation triggers

ECT service consultation triggers

Monitoring targets

Vital sign monitoring

Laboratory monitoring

Supportive care priorities

History

Presenting symptoms

Core psychomotor features

Symptom timeline and triggers

Onset and tempo

Medication history

Risk factors

Psychiatric diagnoses

Medical and toxic causes

Collateral and social history

Collateral sources

Functional baseline

Family history

Physical Exam

Vital signs and general appearance

Vital sign targets and alarm thresholds

General appearance

Motor examination

Rigidity assessment

Additional motor signs

Behavioral observation

BFCRS screening items

Neurologic examination

Focal neurologic signs

Serotonin syndrome signs

Signs of encephalitis

Skin and pressure area assessment

Differential Diagnosis

Life-threatening mimics

Neuroleptic malignant syndrome

Non-convulsive status epilepticus

Anti-NMDA receptor encephalitis

Malignant catatonia itself

Psychiatric mimics

Acute psychosis without catatonia

Severe major depressive episode

Stiff-person syndrome

Neurologic mimics

Locked-in syndrome

Akinetic mutism or abulia

Late-stage Parkinson disease

Serotonin syndrome

Toxic and metabolic mimics

Substance intoxication

Severe metabolic encephalopathy

Delirium with psychomotor retardation

Laboratory Tests

Core workup

Complete blood count

Comprehensive metabolic panel

Creatine kinase

Extended medical workup

Thyroid stimulating hormone

Ammonia

Toxicology screen

Blood cultures

Autoimmune and CSF workup

Anti-NMDA receptor antibody panel

CSF analysis

Additional autoimmune markers

Monitoring labs

Renal function and myoglobin

Electrolyte monitoring

Coagulation

Diagnostic Tests

Scoring Systems

Bush-Francis Catatonia Rating Scale (BFCRS)

DSM-5-TR diagnostic criteria

Catatonia Quick Screen (CQS)

Lorazepam Challenge Test (LCT)

MRI

Brain MRI indications in catatonia

MRI findings in specific conditions

MRI protocol considerations

CT

CT head indications

CT limitations in catatonia

CT body if paraneoplastic syndrome suspected

Ultrasound

Pelvic ultrasound

Point-of-care ultrasound (POCUS) for hemodynamic assessment

Ultrasound-guided procedures

EEG

EEG indications

EEG interpretation in catatonia

Disposition

Admission criteria

All new-onset catatonia requires inpatient admission

Psychiatric inpatient unit indications

Medical inpatient unit indications

ICU indications

Malignant catatonia features

Airway compromise

ECT delivery in ICU setting

Transfer criteria

Transfer to tertiary center triggers

Discharge criteria

Catatonic features resolved on BFCRS

Oral intake adequate and medications taken by mouth

Vital signs stable without autonomic instability

Underlying cause identified and treatment plan in place

Treatment

Initial stabilization

Supportive care bundle

Lorazepam challenge and titration

Lorazepam challenge test

Lorazepam maintenance dosing

Alternative benzodiazepines if lorazepam unavailable

Electroconvulsive therapy (ECT)

ECT indications

ECT protocol

Pre-ECT checklist

Medication management

Dopamine antagonists

Second-line pharmacotherapy

Medications to avoid

Treatment of underlying cause

Autoimmune encephalitis

Substance withdrawal catatonia

Mood disorder-related catatonia

Benzodiazepine taper

Taper principles

Monitoring during taper

Special Populations

Pregnancy

Pregnancy considerations in catatonia

ECT in pregnancy

Medication adjustments in pregnancy

Geriatric

Atypical presentations in older adults

Benzodiazepine dosing in geriatric patients

Comorbidity management

Pediatrics

Catatonia recognition in children and adolescents

Lorazepam dosing in pediatrics

ECT in pediatrics

Underlying causes in pediatrics

Background

Epidemiology

Prevalence and setting

Psychiatric associations

Medical and toxic causes

Recurrence

Pathophysiology

Neurotransmitter models

Neural circuit model

Malignant catatonia mechanism

Therapeutic Considerations

Benzodiazepine evidence base

ECT evidence base

Antipsychotic caution

Treatment of underlying etiology

Patient Discharge Instructions

copy discharge instructions

Catatonia home care instructions

Warning signs to return to the emergency department immediately

Follow-up appointments

Lifestyle and prevention

References

Guidelines and key sources

Primary references

Supporting references

Coding references

Diagnostic coding