Ketamine Saves the Day: Priapism in a Pediatric Psychiatric Patient.

Priapism is an adverse effect of medications used to treat psychiatric disorders. Often, this condition is self-limiting but may re- quire urologic intervention involving aspiration and injection to induce detumescence. A case of a 15-year-old patient with priapism secondary to a long-acting stimulant is presented to describe the effectiveness of ketamine treatment for priapism. CASE A 15-year-old boy with a medical history significant for autism, attention deficit/hyperactivity disorder, and mild men- tal retardation was transferred from a children's psychiatric hospital to the pediatric emergency department (PED) with a chief complaint of priapism. The patient had a long-standing history of extreme hyperactivity despite trials of multiple med- ications. Dexmethylphenidate (Focalin XR, 30 mg daily) was recently discontinued because of facial tics and several self- resolving episodes of priapism. The patient had experienced 2 previous episodes of priapism related to trazodone (Oleptro) that was subsequently stopped as a result. He remained only on the following 2 other medications for a history of poor sleep: doxepin (Silenor) 20 mg daily (tricyclic antidepressant) and melatonin 10 mg daily at night. However, since discontinuing the stimulant medication, the patient had become overwhelm- ingly hyperactive to the point of self-injury and he was volun- tarily admitted to the children's psychiatric hospital for evaluation and treatment. On the first day of hospitalization, the doxepin dose was decreased and Focalin XR was reinitiated at midday with subsequent development of priapism later that night. The following morning, a second dose of Focalin XR 20 mg was given. By the early afternoon, the erection had persisted. Application of an ice pack to the penis and oral pseu- doephedrine (Sudafed) 60 mg was administered without detu- mescence. The patient was then transferred to the PED after approximately 14 hours of priapism. OnarrivaltothePED,thepatientwasinvisiblepainandwas, at times, combative with staff. His vital signs were the following: temperaturewas 37°C; pulse rate, 97 beatsper minute; respiratory rate, 17 breaths per minute; blood pressure, 155/75 mm Hg; and oxygen saturation, 100% in room air. Physical examination re- vealed a well developed, well nourished young man who was oriented to person, place, and time. The head was normocephalic and atraumatic. The lungs were clear to auscultation bilaterally without rales, rhonchi, or wheezes. Cardiovascular examination revealed a normal rate and heart sounds, strong femoral pulses bilaterally, and brisk capillary refill. The abdomen was neither distended nor tender. Genitourinaryexamination revealed a cir- cumcised phallus with an orthotopic urethral meatus with a small blind appearing pit at the ventral aspect of the glans, bi- lateral descended testicles, and an erect penis extremely tender to palpation. No lower extremity edema was revealed. Neuro- logical examination was nonfocal. The pediatric urology service was consulted and recom- mended aspiration of the corpora and injection with phenyleph- rine to induce detumescence. Sedation was deemed necessary to perform a safe proceduregiven the patient's progressively worsen- ing hyperactivity and inability to cooperate with medical staff. Because the patient was uncooperative for placement of an intravenous catheter, 4-mg/kg intramuscular ketamine sedation was provided and used. Routine monitoring including end-tidal CO2 was performed according to standard departmental protocol. The patient's phallus softened within 2 to 3 minutes of admin- istration of ketamine, and an aspiration of the corpora was not performed. A simple penile block was performed and a pres- sure dressing was applied. The dressing was removed after 1 hour and the phallus remained detumesced. The patient was admitted to the pediatric urology service for observation over- night. Priapism did not recur. Dextroamphetamine (Adderall) 10 mg 3 times daily resulted in acceptable hyperactivity con- trol. There was no report of recurrence of priapism at the time of 6-week follow-up with the pediatric urology service.