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) | |||
*Dystonia of any striated muscle group: | |||
**Torticollar reaction | |||
**Buccolingual reaction | |||
**Oculogyric crisis | |||
**Promandibular dystonia | |||
**Lingual dystonia | |||
**Kyphosis/lordosis/scoliosis | |||
**Trismus | |||
**Facial grimacing | |||
**Tortipelvic crisis | |||
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* History of recent drug exposure or increase in drug dosage | |||
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==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: | [[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
- 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.