(P51) Management of Severe Dysmenorrhea Using Esketamine

Chief Complaint : A 27-year-old female presented to the Emergency Department with a chief
complaint of severe pelvic and abdominal pain

History of Present Illness : The patient had menarche at age 13. From menarche onwards, she
had had severe pelvic and abdominal pain during the first five days of her menstrual cycle. She
reported never being worked up for secondary causes of dysmenorrhea. The patient had a
history of using a wide variety of oral over-the-counter anaglesic medications, including
ibuprofen, paracetamol, ketoprofen and naproxen, often in doses above the recommended
daily maximum. She described the pain as stabbing, localized in the right and left lower
abdominal quadrants, radiating in a belt-like fashion, with a visual analog scale (VAS) score of
9/10. Previous episodes of dysmenorrhea sometimes presented with syncope, loss of control
over anal sphincters, nausea and vomiting. A similar type of pain, accompanied by nausea and
vomiting, was reported by the patient during the ovulation phase of her menstrual cycle,
although such pain was of a significantly lower severity (estimated VAS 5/10).

Pertinent Physical Exam: The patient was afebrile, with a peripheral oxygen saturation of 99%. Cardiac action was rhythmic, with clearly audible
heart sounds and without noticeable murmurs or bruits. Respiratory lung sounds were normal
on auscultation. The abdomen was in the level of the sternum, without visible scars or
deformities, tender on palpation in the left and right lower quadrants, without palpable
organomegaly. The extremities were symmetrical, with no visible or palpable oedema and
symmetrically palpable peripheral arterial pulses. Blood pressure was 100/60 mmHg, with a
cardiac pulse of 105 beats per minute.

Pertinent Laboratory Data: A basic laboratory workup, consisting of a complete blood count,
blood glucose level, hepatic transaminases, urea, creatinine, c-reactive protein, serum amylases
and lipases was done. All of the measured parameters were within reference intervals adjusted
for patient age and gender.

Case Discussion: As the patient was mildly hypotensive and reported limited oral
intake in the three days leading up to her emergency department visit, a peripheral venous
catheter was placed and parenteral rehydration was ordered, using 500mL of 0.9% sodium
chloride infusion over 45 minutes. Another peripheral venous catheter was placed in the
opposite arm to the first one and an infusion of 100mg of ketoprofen diluted in 500mL of 0.9%
sodium chloride was started. Following the infusions, the patient reported no pain relief at all,
with the estimated VAS still being 9/10. An infusion of 1g of paracetamol in 100mL of fluid was
ordered, once again with no improvement in the VAS. Since the emergency department
described in this abstract has no access to opioid analgesics due to hospital policy, esketamine

was chosen as the next line agent. An infusion was prepared with 2.5mg of esketamine
(0.05mg/kg) in 100mL of 0.9% sodium chloride and was administered over a period of 35
minutes. Following the infusion, the patient reported a significant decrease in VAS – from 9/10
to 4/10. Following the achievement of pain relief, the patient was administered a 500mL
infusion of a fixed combination of various B vitamins. Blood pressure was also increased to
125/80 following the administration of the aforementioned infusions. The patient was
discharged home hemodinamically stable, with a recommendation of taking oral etoricoxib
120mg once daily for pain relief and contacting a gynecology clinic for the purpose of
performing a workup for secondary causes of dysmenorrhea. Although there is sparse literature
on the topic of using low-dose esketamine for analgesia in the emergency department, this case
demonstrates its impressive efficacy in the absence of opioid analgesics.

References and Acknowledgements (Optional): We thank the patient for providing us with consent to present the diagnosis and management of her condition as a case report at the MEMC.