Dystonic reaction: Difference between revisions
Neil.m.young (talk | contribs) (Text replacement - "==Diagnosis==" to "==Evaluation==") |
No edit summary |
||
| Line 6: | Line 6: | ||
===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 | |||
*25% of patients treated with [[Haldol]] 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 | |||
== | ==Clinical Features== | ||
*History of recent drug exposure or increase in drug dosage | *History of recent drug exposure or increase in drug dosage | ||
*Thorough drug history (prescription, over the counter, herbals, illegal) | *Thorough drug history (prescription, over the counter, herbals, illegal) | ||
| Line 79: | Line 79: | ||
*Trifluoperazine | *Trifluoperazine | ||
*Triflupromazine | *Triflupromazine | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Jaw spasms DDX}} | {{Jaw spasms DDX}} | ||
==Evaluation== | |||
*Normally a clinical diagnosis | |||
*Consider [[urine toxicology]] if no offending agent given by history | |||
==Management== | ==Management== | ||
| Line 107: | Line 108: | ||
==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. | ||
Revision as of 12:25, 24 September 2017
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
Predisposing Factors
- Young age
- Family history of dystonic reaction
- History of EtOH or drug use
- Associated with administration of antiemetics or antipsychotic medications
- 25% of patients treated with Haldol 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
Clinical Features
- History of recent drug exposure or increase in drug dosage
- Thorough drug history (prescription, over the counter, herbals, illegal)
- Physical exam is usually normal except for dystonia of any striated muscle group. Some common presentations include:
- Torticollar reaction
- Buccolingual reaction
- Oculogyric crisis
- Promandibular dystonia
- Lingual dystonia
- Kyphosis/lordosis/scoliosis
- Trismus
- Facial grimacing
- Tortipelvic crisis
Medications Associated with Dystonic Reaction
- Amitriptyline
- Amoxaine
- Azatadine
- Buproprion
- Chlorpromazine
- Chlorprothixene
- Cimetiddine
- Cisapride
- Cocaine
- Clomipramine
- Clozapine
- Cyclizine
- Dexgtromethorphan
- Diazepam
- Diphenhydramine
- Doxepin
- Etomidate
- Fluoxetine
- Fluphenazine
- Fluvoxamine
- Haloperidol
- Imipramine
- Ketamine
- Lozapine
- Mesoridazine
- Methohexital
- Metoclopraminde
- Olanzpine
- Paroxetine
- Perphenazine
- Phenelzine
- Pheyntoin
- Pimozide
- Prochlorperazine
- Promazine
- Promethazine
- Propofol
- Quietiapine
- ranitidine
- Risperidone
- Sertraline
- Thiethylperazine
- Thiopental
- Thioridazine
- Thiothixene
- Tigabine
- tranylcypromine
- Trifluoperazine
- Triflupromazine
Differential Diagnosis
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
Evaluation
- Normally a clinical diagnosis
- Consider urine toxicology if no offending agent given by history
Management
- Anticholinergic medication:
- Diphenhydramine: 50-100mg over 2 minutes
- Benztropine: 1-2mg in adults 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 dystoni
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
- Diphenhydramine: 12.5-50mg PO TID-QID
- Benztropine: 1-2mg PO BID
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.