Dystonic reaction: Difference between revisions

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==Background==
==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 (e.g. prescription, over the counter, herbals, illegal)  
* adverse extrapyramidal effect (intermittent spasmodic or sustained involuntary contractions of muscles) that occurs shortly after initiation of new drugs
*Dystonia of any striated muscle group:
* rarely life threatening but patient is in distress from pain and discomfort
**Torticollar reaction
* men are affected more frequently than women
**Buccolingual reaction  
* predisposing factors:
**Oculogyric crisis
* young age
**Promandibular dystonia
* family history of dystonic reaction
**Lingual dystonia
* history of EtOH or drug use
**Kyphosis/lordosis/scoliosis  
* associated with administration of antiemetics or antipsychotic medications
**Trismus
* 25% of patients treated with Haldol have been known to develop this reaction
**Facial grimacing
* reaction usually occurs within 48 hrs of drug treatment but can occur up to 5 days after starting therapy
**Tortipelvic crisis
* severity and onset of reaction depends on an individual, no association with dose, drug type, potency of drug, or duration of treatment
* many theories on what causes the reaction
* direct blockade of central dopaminergic receptors
* imbalance of neurotransmitters (dopamine and acetylcholine) causing excessive cholinergic activity
* combination of dopamine blockade initially by the offending agent and later dopamine activation in nigrostriatal system
 
 
==Diagnosis==
 
 
* 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
* oromandibular 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
 
==Work-Up==
 
 
* consider Utox if no offending agent given by history
==DDx==
 
 
 
* tetanus
* hysterical conversion disorder
* dislocation of mandible
* electrolyte abnormality (Calcium, magnesium)
* meningitis
* seizure disorder
* strychnine poisoning
* akathisia
* stroke
* drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)
 
==Treatment==
 
 
* Anticholinergic medication:
* Diphenhydramine: 50-100mg over 2 minutes
* Benztropine: 1-2 mg 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
 
==Source==
 
 
Adapted from Harwood-Nuss


emedicine
==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 DDX}}


==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==
<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.


[[Category:Tox]]
[[Category:ENT]]
[[Category:Neurology]]
[[Category:Psychiatry]]
[[Category:Toxicology]]

Revision as of 12:29, 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 (e.g. prescription, over the counter, herbals, illegal)
  • Dystonia of any striated muscle group:
    • 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

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.