Valproic acid (VPA) is a wide spectrum antiepileptic medication indicated for seizure prophylaxis across the spectrum of epilepsy. Since coming into clinical use, VPA has also been recommended for the management of a variety of other pathologies, including, most notably, mood stabilization in the manic patient.VPA's common adverse effects include gastrointestinal, influenza-like symptoms, headache, and difficulties with sleep; nonetheless, in rare instances, VPA has been noted to cause the severe and potentially lethal condition of hyperammonemia with encephalopathy (VIHE).VIHE is the result of a dose-independent increase in ammonia levels. Often the patient is asymptomatic; if symptoms reach clinical threshold, lethargy is most common, though seizures, focal neurologic deficits and even coma are possible. VIHE can occur in patients despite normal hepatic function, normal loading doses, chronic stable doses and normal free serum drug levels. Once the diagnosis is confirmed, the first approach for symptomatic patients is to discontinue VPA, start alternative mood stabilizer as indicated, and supplement hyperammonemia treatment with lactulose, carnitine or carglumic acid. Below is a case report of VIHE that developed in an adolescent girl with a history of Bipolar I Disorder who was hospitalized in our facility for stabilization of mania. As demonstrated below, early diagnosis of VIHE is pivotal in reducing morbidity and ultimately can be life-saving.
Trauma-informed care (TIC) is a philosophy and framework for delivering health care that respects the impacts that trauma has had on individuals’ lives. Most individuals experience and survive a trauma in their lifetimes, and many patients can find the experience of emergency department (ED) treatment too reactive. These anxieties may arise from the stress and pain of medical illness, triggering interactions with staff, or the chaotic environment of the ED. TIC also considers the impact of trauma on ED staff and providers. This chapter describes core elements of TIC in EDs and crisis services that can promote patient-centered and recovery-oriented care. The TIC approach is contrasted with historic—and still common—notions of traditional medicine that are often perceived by patients to be dehumanizing. Psychological first aid is a therapeutic approach that helps individual clinicians apply TIC to patients in the aftermath of individual or collective trauma.
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