A child with psychotic symptoms and attention-deficit hyperactivity disorder who developed extrapyramidal symptoms while on a combination of risperidone, methylphenidate, sertraline, tropisetron and ketorolac is described herein. The extrapyramidal symptoms resolved with the administration of benztropine, an anticholinergic drug. Successful treatment of his psychosis was achieved by decreasing the dose of risperidone, followed by slow upward titration.
HE INCREASED use of endotracheal intubation, endoral examinations and diagnostic and aspiration bronchoscopy in surgery today has made it necessary for the anesthesiologist to provide optimum and uniform laryngo-tracheal topical anesthesia. Several methods have been proposed to prepare a patient for intubation or bronchoscopy. Each provides varying degrees of topical analgesia.The trans-crico-thyroid membrane (TCTM) route of providing local or topical anesthesia for the larynx and trachea was first introduced by Canuyt in France over 50 years ago,' but was used little until Harkens and Salzberg2 advocated its used for bronchoscopy. Bonica3 described its use for endotracheal intubation. The distinct advantages of this method have not been fully appreciated because clinical experience has been limited, and because there have been, we believe, false impressions as to the dangers of the technique.In order to provide optimal local anesthesia for endoscopy and endotracheal intubation, the mucous membrane of the larynx, trachea and carina must be anesthetized. T h e larynx can be anesthetized more or less completely by the spray application or by the direct application of the anesthetic agent, but the carina receives little or no anesthesia by these methods. Complete anesthesia can best be obtained by the injection of the anesthetic agent into the trachea, where it will come into contact with the mucous membrane of the trachea and by virtue of the reflex coughing will be applied over the larynx and carina. This, we believe, provides the optimum of anesthesia t o all sensitive structures with which the endotracheal instruments will come into contact and thus prevents unnecessary bucking and bronchospasm, which are occasionally followed by distressing cardiovascular and respiratory sequelae. Equally important is the fact that the resistance from the patient due to the incomplete local anesthesia prevents the successful progress of the operative or diagnostic procedure.TCTM anesthesia has the advantage of providing excellent anesthesia for the larynx, trachea and carina, which permits the endoscopist to make a thorough and safe examination. Most bronchoscopic examinations in our hospital are done with the patient asleep, but minimal quantities of the intravenous anesthetic agent are needed because of the adequate local anesthesia. 386
ALOTHANE (Fluothanes) has beenH a suspect agent as a result of severa1 recent alluding to it as a hepatotoxic chemical. While none of the cases reported showed a conclusive relationship between halothtane and the observed liver pathology, doubts were nevertheless raised. It therefore became incumbent upon each department of anesthesia to search its records for possible cases of liver pathology secondary to halothane anesthesia. The inference projected in the recent literature was that a lack of awareness may have allowed similar cases to go unrecognized as to true etiology.A thorough review was made in our hospital covering the period May 1960 through June 1963. In our 908-bed general hospital, we average approximately 15,000 a n e s t h e t i c procedures a year, which include an average of 3000 obstetric anesthetics in which halothane has not been used. Halothane was introduced in our hospital in May of 1960, and in 1962 we were t h e fourteenth largest user of this agent in the United state^.^ A survey of the surgical division was conducted to see if there were any cases of liver complication reported during the hospital postoperative period. All cases of hepatitis admitted on t h e medical service during the period of study were also analyzed t o determine if any of the cases had received halothane, been discharged from the surgical service, and were then readmitted for hepatitis on the medical service. All autopsies during this period which demonstrated any major liver pathology were analyzed. RESULTSDuring the period of study, 13,024 halothane and 7160 cyclopropane anesthetics were administered, accounting for 56 per cent of all surgical anesthetics (halothane 36 per cent, cyclopropane 20 per cent). The remainder of the cases were done under either sodlium thiopental-nitrous oxide-diethyl ether, or some form of regional anesthesia. All halothane anesthetics are administered utilizing a high flow (4 liters nitrous oxide and 4 liters oxygen) semiclhosed technic.Fifteen anesthetic machines are used in our department to administer halothane
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