Dystonic reaction: Difference between revisions

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==Clinical Features==
==Clinical Features==
*History of recent drug exposure or increase in drug dosage
*History of recent drug exposure or increase in drug dosage (e.g. prescription, over the counter, herbals, illegal)  
*Thorough drug history (prescription, over the counter, herbals, illegal)  
*Dystonia of any striated muscle group:
 
**Torticollar reaction
#Physical exam is usually normal except for dystonia of any striated muscle group. Some common presentations include:
**Buccolingual reaction  
##Torticollar reaction
**Oculogyric crisis
##Buccolingual reaction  
**Promandibular dystonia
##Oculogyric crisis
**Lingual dystonia
##Promandibular dystonia
**Kyphosis/lordosis/scoliosis  
##Lingual dystonia
**Trismus
##Kyphosis/lordosis/scoliosis  
**Facial grimacing
##Trismus
**Tortipelvic crisis
##Facial grimacing
##Tortipelvic crisis  


==Medications Associated with Dystonic Reaction==
==Medications Associated with Dystonic Reaction==
*Amitriptyline
*[[Amitriptyline]]
*Amoxaine
*Amoxapine
*Azatadine
*Azatadine
*Buproprion
*[[Bupropion]]
*Chlorpromazine
*[[Chlorpromazine]]
*Chlorprothixene
*Chlorprothixene
*Cimetiddine
*[[Cimetidine]]
*Cisapride
*Cisapride
*Cocaine
*[[Cocaine]]
*Clomipramine
*Clomipramine
*Clozapine
*[[Clozapine]]
*Cyclizine
*Cyclizine
*Dexgtromethorphan
*[[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]]
*Metoclopraminde
*[[Metoclopramide]]
*Olanzpine
*[[Olanzapine]]
*Paroxetine
*Paroxetine
*Perphenazine
*Perphenazine
*Phenelzine
*Phenelzine
*Pheyntoin
*[[Phenytoin]]
*Pimozide
*Pimozide
*Prochlorperazine
*[[Prochlorperazine]]
*Promazine
*Promazine
*Promethazine
*[[Promethazine]]
*Propofol
*[[Propofol]]
*Quietiapine
*[[Quetiapine]]
*ranitidine
*[[Ranitidine]]
*Risperidone
*[[Risperidone]]
*Sertraline
*Sertraline
*Thiethylperazine
*Thiethylperazine
*Thiopental
*[[Thiopental]]
*Thioridazine
*Thioridazine
*Thiothixene
*Thiothixene
*Tigabine
*Tigabine
*tranylcypromine
*Tranylcypromine
*Trifluoperazine
*Trifluoperazine
*Triflupromazine
*Triflupromazine
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==Management==
==Management==
#Anticholinergic medication:  
*[[Anticholinergic]] medication:  
##Diphenhydramine: 50-100mg over 2 minutes
**[[Diphenhydramine]]: 50-100mg over 2 minutes
##Benztropine: 1-2mg in adults over 2 minutes
**[[Benztropine]]: 1-2mg in adults over 2 minutes
##Biperiden
**[[Biperiden]]
##Trihexyphenidyl 2mg PO BID
**[[Trihexyphenidyl]] 2mg PO BID
##IV > IM > PO
**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)
**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
**Patients may require more than one dose of IV medication before symptoms resolve completely
#Benzodiazepines  
*[[Benzodiazepines]]
#Airway Management
*Airway Management
##rare, but may be indicated in patients with severe respiratory distress from laryngeal or pharyngeal dystoni  
**Rare, but may be indicated in patients with severe respiratory distress from laryngeal or pharyngeal dystoni


==Disposition==
==Disposition==

Revision as of 20:47, 30 September 2019

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

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.