Neuroleptic malignant syndrome: Difference between revisions
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Revision as of 14:03, 10 February 2014
Background
- Life threatening neurologic emergency associated with the use of neuroleptic agents
- 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:
- 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
DDX
- 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 Toxidrome
- Diaphoresis, rigidity, elevated CK are absent
- Flushing, mydriasis, bladder distension are common
- Sympathomimetics
- Rigidity is not seen
- Meningitis/encephalitis
- Delirium Tremens
- Heat Stroke
Work-Up
- 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
- Stop causative agent
- If precipitant is discontinuation of dopaminergic therapy, it should be restarted
- Supportive Care
- Fluid resuscitation
- Cooling measures
- Consider paralysis with nondepolarizing agents
- Agitation control with benzos
- Blood pressure control with clonidine or nitroprusside
- Medical therapy[1]
- Controversial; efficacy is unclear and disputed
- 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
- ECT
- Dantrolene
- Controversial; efficacy is unclear and disputed
Complications
- Dehydration
- Electrolyte imbalance
- ARF (rhabdo)
- Dysrhythmias
- ACS
- Respiratory failure
- Chest wall rigidity, aspiration PNA, PE
- DIC
- Seizure (hyperthermia, electrolyte derangements)
- Hepatic failure
- Sepsis
Source
<references>
- ↑ Addonizio G, Susman VL, Roth SD. Neuroleptic malignant syndrome: review and analysis of 115 cases. Biol Psychiatry. Aug 1987;22(8):1004-20