Neuroleptic malignant syndrome: Difference between revisions
Line 52: Line 52:


==Treatment==
==Treatment==
#Stop causative agent
*The causative agent should be stopped
##If precipitant is discontinuation of dopaminergic therapy, it should be restarted
##If precipitant is discontinuation of dopaminergic therapy, it should be restarted
#Supportive Care
===Supportive Care===
##Fluid resuscitation
#Agitation should be controlled with [[Benzodiazepines]]
##Cooling measures
#Fluid resuscitation
###Consider paralysis with nondepolarizing agents
#Cooling measures
##Agitation control with benzos
 
##Blood pressure control with clonidine or nitroprusside
===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>===
#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; efficacy is unclear and disputed
#Dantrolene
###Dantrolene
##Skeletal muscle relaxant; may cause hepatotoxicity in pts w/ liver disease
####Skeletal muscle relaxant; may cause hepatotoxicity in pts w/ liver disease
##Consider only in pts with severe rigidity
####Consider only in pts with severe rigidity
##Give 0.25-2mg/kg IV q6-12hr
####Give 0.25-2mg/kg IV q6-12hr
#Bromocriptine
###Bromocriptine
##Dopamine agonist
####Dopamine agonist
##Give 2.5mg NG q6-8hr
####Give 2.5mg NG q6-8hr
#Amantadine
###Amantadine
##Alternative to bromocriptine
####Alternative to bromocriptine
##Give 100mg PO/NG initially; titrate up as needed to max dose 200mg q12hr
####Give 100mg PO/NG initially; titrate up as needed to max dose 200mg q12hr
###ECT


==Complications==
==Complications==

Revision as of 01:25, 5 May 2014

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

  1. Altered Mental Status
    1. Agitated delirium progressing to stupor/coma
  2. Muscular Rigidity
    1. Generalized, "lead pipe" rigidity
  3. Hyperthermia
    1. >38C (87%)
    2. >40C (40%)
  4. Autonomic Instability
    1. Tachycardia
    2. Hypertension
    3. Diaphoresis

DDX

  1. Serotonin Syndrome
    1. More likely to have hyperreflexia, myoclonus, ataxis, N/V, diarrhea
    2. Rigidity and hyperthermia, if present, is less severe than in NMS
  2. Malignant Hyperthermia
    1. Distinguish by clinical setting (use of inhalational anesthetics or sux)
    2. Hyperthermia, muscle rigidity, and dysautonomia is similar to NMS though more fulminant
  3. Anticholinergic Toxicity
    1. Diaphoresis, rigidity, elevated CK are absent
    2. Flushing, mydriasis, bladder distension are common
  4. Sympathomimetics
    1. Rigidity is not seen
  5. Meningitis/encephalitis
  6. Delirium Tremens
  7. Heat Stroke

Work-Up

  1. Total CK
    1. Typically >1000
    2. Correlates with degree of rigidity
  2. CBC
    1. WBC >10K is typical
  3. Chemistry
    1. May show hypocalcemia, hypomagnesemia, hyperkalemia, metabolic acidosis
  4. UA
    1. Myoglobinuria (from rhabdo)
  5. LFT
    1. Transaminitis
  6. CT/LP
    1. CSF may have mildly elevated protein

Treatment

  • The causative agent should be stopped
    1. If precipitant is discontinuation of dopaminergic therapy, it should be restarted

Supportive Care

  1. Agitation should be controlled with Benzodiazepines
  2. Fluid resuscitation
  3. Cooling measures

Directed Medical therapy[4]

  • Controversial with unclear and disputed efficacy
  1. Dantrolene
    1. Skeletal muscle relaxant; may cause hepatotoxicity in pts w/ liver disease
    2. Consider only in pts with severe rigidity
    3. Give 0.25-2mg/kg IV q6-12hr
  2. Bromocriptine
    1. Dopamine agonist
    2. Give 2.5mg NG q6-8hr
  3. Amantadine
    1. Alternative to bromocriptine
    2. Give 100mg PO/NG initially; titrate up as needed to max dose 200mg q12hr

Complications

  1. Dehydration
  2. Electrolyte imbalance
  3. ARF (rhabdo)
  4. Dysrhythmias
  5. ACS
  6. Respiratory failure
    1. Chest wall rigidity, aspiration PNA, PE
  7. DIC
  8. Seizure (hyperthermia, electrolyte derangements)
  9. Hepatic failure
  10. Sepsis

Source

<references>

  1. ↑ 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
  2. ↑ Trollor JN, Chen X, Sachdev PS. Neuroleptic malignant syndrome associated with atypical antipsychotic drugs. CNS Drugs. 2009;23(6):477-92
  3. ↑ 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
  4. ↑ Addonizio G, Susman VL, Roth SD. Neuroleptic malignant syndrome: review and analysis of 115 cases. Biol Psychiatry. Aug 1987;22(8):1004-20
Retrieved from "https://www.wikem.org/w/index.php?title=Neuroleptic_malignant_syndrome&oldid=20542"