Dystonic reaction: Difference between revisions
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*Rarely life threatening but patient is in distress from pain and discomfort | *Rarely life threatening but patient is in distress from pain and discomfort | ||
*Men > Women | *Men > Women | ||
*Dystonia is idiosyncratic (not dose-related) | |||
===Predisposing Factors=== | ===Predisposing Factors=== | ||
*Young age | |||
*Family history of dystonic reaction | |||
*History of EtOH or drug use | |||
*Associated with administration of [[antiemetics]] or [[antipsychotic]] medications (in 10-60% of treated patients) | |||
*25% of patients treated with [[haloperidol]] have been known to develop this reaction | |||
*Reaction usually occurs within 48 hrs of drug treatment but can occur up to 5 days after starting therapy | |||
*Severity and onset of reaction depends on an individual, no association with dose, drug type, potency of drug, or duration of treatment | |||
= | ===Medications Associated with Dystonic Reaction=== | ||
*[[Amitriptyline]] | |||
*Amoxapine | |||
==Medications Associated with Dystonic Reaction== | |||
*Amitriptyline | |||
* | |||
*Azatadine | *Azatadine | ||
* | *[[Bupropion]] | ||
*Chlorpromazine | *[[Chlorpromazine]] | ||
*Chlorprothixene | *Chlorprothixene | ||
* | *[[Cimetidine]] | ||
*Cisapride | *Cisapride | ||
*Cocaine | *[[Cocaine]] | ||
*Clomipramine | *Clomipramine | ||
*Clozapine | *[[Clozapine]] | ||
*Cyclizine | *Cyclizine | ||
* | *[[Dextromethorphan]] | ||
*Diazepam | *[[Diazepam]] | ||
*Diphenhydramine | *[[Diphenhydramine]] | ||
*Doxepin | *[[Doxepin]] | ||
*Etomidate | *[[Etomidate]] | ||
*Fluoxetine | *[[Fluoxetine]] | ||
*Fluphenazine | *Fluphenazine | ||
*Fluvoxamine | *Fluvoxamine | ||
*Haloperidol | *[[Haloperidol]] | ||
*Imipramine | *Imipramine | ||
*Ketamine | *[[Ketamine]] | ||
*Lozapine | *Lozapine | ||
*Mesoridazine | *Mesoridazine | ||
*Methohexital | *[[Methohexital]] | ||
* | *[[Metoclopramide]] | ||
* | *[[Olanzapine]] | ||
*Paroxetine | *Paroxetine | ||
*Perphenazine | *Perphenazine | ||
*Phenelzine | *Phenelzine | ||
* | *[[Phenytoin]] | ||
*Pimozide | *Pimozide | ||
*Prochlorperazine | *[[Prochlorperazine]] | ||
*Promazine | *Promazine | ||
*Promethazine | *[[Promethazine]] | ||
*Propofol | *[[Propofol]] | ||
* | *[[Quetiapine]] | ||
* | *[[Ranitidine]] | ||
*Risperidone | *[[Risperidone]] | ||
*Sertraline | *Sertraline | ||
*Thiethylperazine | *Thiethylperazine | ||
*Thiopental | *[[Thiopental]] | ||
*Thioridazine | *Thioridazine | ||
*Thiothixene | *Thiothixene | ||
*Tigabine | *Tigabine | ||
* | *Tranylcypromine | ||
*Trifluoperazine | *Trifluoperazine | ||
*Triflupromazine | *Triflupromazine | ||
== | ==Clinical Features== | ||
* | [[File:Dystonia2010.jpg|thumb|Medication-induced dystonia.]] | ||
*History of recent drug exposure or increase in drug dosage (e.g. prescription, over the counter, herbals, illegal) | |||
*Dystonia of any striated muscle group: | |||
**[[Torticollar reaction]] -> twisted neck or facial muscle spasm | |||
**Buccolingual reaction -> protruding or pulling sensation of the tongue | |||
**Oculogyric crisis -> roving or deviated gaze | |||
**Promandibular dystonia | |||
**Lingual dystonia | |||
**Opisthotonic -> severe hyperextension of entire spinal column | |||
**Kyphosis/lordosis/scoliosis | |||
**Trismus | |||
**Facial grimacing | |||
**Tortipelvic crisis -> abdominal rigidity and pain | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Movement disorder DDX}} | |||
{{Jaw spasms DDX}} | {{Jaw spasms DDX}} | ||
{{Neck pain DDX}} | |||
==Evaluation== | |||
*Normally a clinical diagnosis | |||
*Consider [[urine toxicology]] if no offending agent given by history | |||
*More chronic neurologic side effects of phenothiazines (akathisia, tardive dyskinesia, parkinsonism) don't usually respond as dramatically to treatment as does acute dystonia | |||
==Management== | ==Management== | ||
*[[Anticholinergic]] medication: | |||
**[[Benztropine]]: 1-2mg in adults over 2 minutes | |||
**[[Diphenhydramine]]: 25-50mg over 2 minutes | |||
**[[Biperiden]] | |||
**[[Trihexyphenidyl]] 2mg PO BID | |||
**IV > IM > PO | |||
**Symptoms will typically begin resolving in 2-15 minutes but may take up to 90 minutes to completely abate (depends on route in which medication was given) | |||
**Patients may require more than one dose of IV medication before symptoms resolve completely | |||
*[[Benzodiazepines]] | |||
*Airway Management | |||
**Rare, but may be indicated in patients with severe respiratory distress from laryngeal or pharyngeal dystonia | |||
==Disposition== | ==Disposition== | ||
*Stop the offending agent (if antipsychotic, speak with patients psychiatrist before just stopping the medication) | *Stop the offending agent (if antipsychotic, speak with patients psychiatrist before just stopping the medication) | ||
*Continue to treat with PO anticholinergic to prevent relapse of symptoms | *Continue to treat with PO anticholinergic to prevent relapse of symptoms (if the culprit is long acting) | ||
** | **[[Benztropine]]: 1-2mg PO BID during 2-3 days | ||
** | **[[Diphenhydramine]]: 25mg PO QID for 24-72 hours | ||
==See Also== | |||
*[[Torticollis]] | |||
*[[Extrapyramidal reaction]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
*Hockberger RS, Richards JR: Thought Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 110: p 1460-1466. | *Hockberger RS, Richards JR: Thought Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 110: p 1460-1466. | ||
Latest revision as of 20:07, 12 May 2022
Background
- Adverse extrapyramidal effect shortly after initiation of new drugs
- intermittent spasmodic or sustained involuntary contractions of muscles
- Rarely life threatening but patient is in distress from pain and discomfort
- Men > Women
- Dystonia is idiosyncratic (not dose-related)
Predisposing Factors
- Young age
- Family history of dystonic reaction
- History of EtOH or drug use
- Associated with administration of antiemetics or antipsychotic medications (in 10-60% of treated patients)
- 25% of patients treated with haloperidol have been known to develop this reaction
- Reaction usually occurs within 48 hrs of drug treatment but can occur up to 5 days after starting therapy
- Severity and onset of reaction depends on an individual, no association with dose, drug type, potency of drug, or duration of treatment
Medications Associated with Dystonic Reaction
- Amitriptyline
- Amoxapine
- Azatadine
- Bupropion
- Chlorpromazine
- Chlorprothixene
- Cimetidine
- Cisapride
- Cocaine
- Clomipramine
- Clozapine
- Cyclizine
- Dextromethorphan
- Diazepam
- Diphenhydramine
- Doxepin
- Etomidate
- Fluoxetine
- Fluphenazine
- Fluvoxamine
- Haloperidol
- Imipramine
- Ketamine
- Lozapine
- Mesoridazine
- Methohexital
- Metoclopramide
- Olanzapine
- Paroxetine
- Perphenazine
- Phenelzine
- Phenytoin
- Pimozide
- Prochlorperazine
- Promazine
- Promethazine
- Propofol
- Quetiapine
- Ranitidine
- Risperidone
- Sertraline
- Thiethylperazine
- Thiopental
- Thioridazine
- Thiothixene
- Tigabine
- Tranylcypromine
- Trifluoperazine
- Triflupromazine
Clinical Features
- History of recent drug exposure or increase in drug dosage (e.g. prescription, over the counter, herbals, illegal)
- Dystonia of any striated muscle group:
- Torticollar reaction -> twisted neck or facial muscle spasm
- Buccolingual reaction -> protruding or pulling sensation of the tongue
- Oculogyric crisis -> roving or deviated gaze
- Promandibular dystonia
- Lingual dystonia
- Opisthotonic -> severe hyperextension of entire spinal column
- Kyphosis/lordosis/scoliosis
- Trismus
- Facial grimacing
- Tortipelvic crisis -> abdominal rigidity and pain
Differential Diagnosis
Movement Disorders and Other Abnormal Contractions
- Chorea
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Hypocalcemia
- Strychnine toxicity
- Acute tetanus
- Parkinson's disease
- Mono amine oxidase inhibitor toxicity
- Phencyclidine toxicity
- Anti-NMDA receptor encephalitis
- Huntington disease
- Wilson's disease
- CVA
- Schizophrenia
- Psychotic agitation
- Dementia
- Lewy body dementia
- Vascular dementia
- Frontotemporal dementia
- Dystonic reaction
- Extrapyramidal reaction
- Torticollis
- Idiopathic movement disorder
Jaw Spasms
- Acute tetanus
- Akathisia
- Conversion disorder
- Drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)
- Dystonic reaction
- Electrolyte abnormality
- Hypocalcemic tetany
- Magnesium
- Mandible dislocation
- Meningitis
- Peritonsillar abscess
- Rabies
- Seizure
- Strychnine poisoning
- Stroke
- Temporomandibular disorder
- Torticollis
Neck pain
- Musculoskeletal
- Torticollis
- Dystonic reaction
- Cervical spondylosis
- Cervical stenosis
- Cancer
- Epidural abscess
- Vertebral osteomyelitis
- Transverse myelitis
- Temporal arteritis
- Epidural hematoma (anticoagulation, hemophilia)
- Cervical disk herniation
- Blunt neck trauma
- Anterior horn disease
- Cervical fractures and dislocations
- Cervical radiculopathy
Evaluation
- Normally a clinical diagnosis
- Consider urine toxicology if no offending agent given by history
- More chronic neurologic side effects of phenothiazines (akathisia, tardive dyskinesia, parkinsonism) don't usually respond as dramatically to treatment as does acute dystonia
Management
- Anticholinergic medication:
- Benztropine: 1-2mg in adults over 2 minutes
- Diphenhydramine: 25-50mg over 2 minutes
- Biperiden
- Trihexyphenidyl 2mg PO BID
- IV > IM > PO
- Symptoms will typically begin resolving in 2-15 minutes but may take up to 90 minutes to completely abate (depends on route in which medication was given)
- Patients may require more than one dose of IV medication before symptoms resolve completely
- Benzodiazepines
- Airway Management
- Rare, but may be indicated in patients with severe respiratory distress from laryngeal or pharyngeal dystonia
Disposition
- Stop the offending agent (if antipsychotic, speak with patients psychiatrist before just stopping the medication)
- Continue to treat with PO anticholinergic to prevent relapse of symptoms (if the culprit is long acting)
- Benztropine: 1-2mg PO BID during 2-3 days
- Diphenhydramine: 25mg PO QID for 24-72 hours
See Also
References
- Hockberger RS, Richards JR: Thought Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 110: p 1460-1466.