Neuroleptic malignant syndrome: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
*Tetrad of:<ref>Gurrera RJ, Velamoor V, Cernovsky ZZ. A Validation Study of the International Consensus Diagnostic Criteria for Neuroleptic Malignant Syndrome. J Clin Psychopharmacol. Aug 22 2013</ref> | *Tetrad of:<ref>Gurrera RJ, Velamoor V, Cernovsky ZZ. A Validation Study of the International Consensus Diagnostic Criteria for Neuroleptic Malignant Syndrome. J Clin Psychopharmacol. Aug 22 2013</ref> | ||
*[[Altered mental status]] | |||
**Agitated delirium progressing to stupor/coma | |||
*Muscular Rigidity | |||
**Generalized, "lead pipe" rigidity | |||
*[[Hyperthermia]] | |||
**>38C (87%) | |||
**>40C (40%) | |||
*Autonomic Instability | |||
**Tachycardia | |||
**Hypertension | |||
**Diaphoresis | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 33: | Line 33: | ||
**Rigidity is not seen | **Rigidity is not seen | ||
*[[Meningitis]]/[[encephalitis]] | *[[Meningitis]]/[[encephalitis]] | ||
*[[Alcohol_Withdrawal | *[[Alcohol_Withdrawal*Delirium_Tremens|Delirium Tremens]] | ||
*[[Heat Stroke]] | *[[Heat Stroke]] | ||
==Diagnosis== | ==Diagnosis== | ||
*Total CK | |||
**Typically >1000 | |||
**Correlates with degree of rigidity | |||
*CBC | |||
**WBC >10K is typical | |||
*Chemistry | |||
**May show hypocalcemia, hypomagnesemia, hyperkalemia, metabolic acidosis | |||
*UA | |||
**Myoglobinuria (from rhabdo) | |||
*LFT | |||
**Transaminitis | |||
*CT/[[LP]] | |||
**CSF may have mildly elevated protein | |||
==Treatment== | ==Treatment== | ||
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*If precipitant is a dopaminergic therapy (L-dopa or Carbidopa) it can be restarted later at lower doses as an outpatient | *If precipitant is a dopaminergic therapy (L-dopa or Carbidopa) it can be restarted later at lower doses as an outpatient | ||
===Supportive Care=== | ===Supportive Care=== | ||
*Agitation should be controlled with [[Benzodiazepines]] | |||
*[[Fluid resuscitation]] | |||
*Cooling measures | |||
===Directed Medical therapy<ref>Addonizio G, Susman VL, Roth SD. Neuroleptic malignant syndrome: review and analysis of 115 cases. Biol Psychiatry. Aug 1987;22(8):1004-20 </ref>=== | ===Directed Medical therapy<ref>Addonizio G, Susman VL, Roth SD. Neuroleptic malignant syndrome: review and analysis of 115 cases. Biol Psychiatry. Aug 1987;22(8):1004-20 </ref>=== | ||
*Controversial with unclear and disputed efficacy | *Controversial with unclear and disputed efficacy | ||
*Dantrolene | |||
**Skeletal muscle relaxant; may cause hepatotoxicity in pts w/ liver disease | |||
**Consider only in pts with severe rigidity | |||
**Give 0.25-2mg/kg IV q6-12hr | |||
*Bromocriptine | |||
**Dopamine agonist | |||
**Give 2.5mg NG q6-8hr | |||
*Amantadine | |||
**Alternative to bromocriptine | |||
**Give 100mg PO/NG initially; titrate up as needed to max dose 200mg q12hr | |||
==Complications== | ==Complications== | ||
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==References== | ==References== | ||
<references> | </references> | ||
[[Category:Psych]] | [[Category:Psych]] | ||
[[Category:Tox]] | [[Category:Tox]] | ||
Revision as of 15:42, 10 June 2015
Background
- Life threatening neurologic emergency associated with the use of neuroleptic agents[1][2]
- Can occur with single dose, increasing dose, or same dose as usual
- May also occur with withdrawal of anti-Parkinson medication or use of antiemetics
- Develops over 1-3 days
- Majority of deaths occur from complications of muscle rigidity
Clinical Features
- Tetrad of:[3]
- Altered mental status
- Agitated delirium progressing to stupor/coma
- Muscular Rigidity
- Generalized, "lead pipe" rigidity
- Hyperthermia
- >38C (87%)
- >40C (40%)
- Autonomic Instability
- Tachycardia
- Hypertension
- Diaphoresis
Differential Diagnosis
- Serotonin Syndrome
- More likely to have hyperreflexia, myoclonus, ataxis, N/V, diarrhea
- Rigidity and hyperthermia, if present, is less severe than in NMS
- Malignant Hyperthermia
- Distinguish by clinical setting (use of inhalational anesthetics or sux)
- Hyperthermia, muscle rigidity, and dysautonomia is similar to NMS though more fulminant
- Anticholinergic Toxicity
- Diaphoresis, rigidity, elevated CK are absent
- Flushing, mydriasis, bladder distension are common
- Sympathomimetics
- Rigidity is not seen
- Meningitis/encephalitis
- Delirium Tremens
- Heat Stroke
Diagnosis
- Total CK
- Typically >1000
- Correlates with degree of rigidity
- CBC
- WBC >10K is typical
- Chemistry
- May show hypocalcemia, hypomagnesemia, hyperkalemia, metabolic acidosis
- UA
- Myoglobinuria (from rhabdo)
- LFT
- Transaminitis
- CT/LP
- CSF may have mildly elevated protein
Treatment
- The causative agent should be stopped
- If precipitant is a dopaminergic therapy (L-dopa or Carbidopa) it can be restarted later at lower doses as an outpatient
Supportive Care
- Agitation should be controlled with Benzodiazepines
- Fluid resuscitation
- Cooling measures
Directed Medical therapy[4]
- Controversial with unclear and disputed efficacy
- Dantrolene
- Skeletal muscle relaxant; may cause hepatotoxicity in pts w/ liver disease
- Consider only in pts with severe rigidity
- Give 0.25-2mg/kg IV q6-12hr
- Bromocriptine
- Dopamine agonist
- Give 2.5mg NG q6-8hr
- Amantadine
- Alternative to bromocriptine
- Give 100mg PO/NG initially; titrate up as needed to max dose 200mg q12hr
Complications
- Dehydration
- Electrolyte imbalance
- Acute renal failure (rhabdo)
- Dysrhythmias
- ACS
- Respiratory failure
- DIC
- Seizure (hyperthermia, electrolyte derangements)
- Hepatic failure
- Sepsis
References
</references>
- ↑ Su YP, Chang CK, Hayes RD, Harrison S, Lee W, Broadbent M, et al. Retrospective chart review on exposure to psychotropic medications associated with neuroleptic malignant syndrome. Acta Psychiatr Scand. Nov 15 2013
- ↑ Trollor JN, Chen X, Sachdev PS. Neuroleptic malignant syndrome associated with atypical antipsychotic drugs. CNS Drugs. 2009;23(6):477-92
- ↑ Gurrera RJ, Velamoor V, Cernovsky ZZ. A Validation Study of the International Consensus Diagnostic Criteria for Neuroleptic Malignant Syndrome. J Clin Psychopharmacol. Aug 22 2013
- ↑ Addonizio G, Susman VL, Roth SD. Neuroleptic malignant syndrome: review and analysis of 115 cases. Biol Psychiatry. Aug 1987;22(8):1004-20