Dystonic reaction: Difference between revisions

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==Background==
==Background==
* adverse extrapyramidal effect (intermittent spasmodic or sustained involuntary contractions of muscles) that occurs shortly after initiation of new drugs
*Adverse extrapyramidal effect shortly after initiation of new drugs
* rarely life threatening but patient is in distress from pain and discomfort
**intermittent spasmodic or sustained involuntary contractions of muscles
* men are affected more frequently than women
*Rarely life threatening but patient is in distress from pain and discomfort
* predisposing factors:
*Men > Women
* young age
*Dystonia is idiosyncratic (not dose-related)
* 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
* 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==
===Predisposing Factors===
* Amitriptyline
*Young age
* Amoxaine
*Family history of dystonic reaction
* Azatadine
*History of EtOH or drug use
* Buproprion
*Associated with administration of [[antiemetics]] or [[antipsychotic]] medications (in 10-60% of treated patients)
* Chlorpromazine
*25% of patients treated with [[haloperidol]] have been known to develop this reaction
* Chlorprothixene
*Reaction usually occurs within 48 hrs of drug treatment but can occur up to 5 days after starting therapy
* Cimetiddine
*Severity and onset of reaction depends on an individual, no association with dose, drug type, potency of drug, or duration of treatment
* 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==
===Medications Associated with Dystonic Reaction===
* consider Utox if no offending agent given by history
*[[Amitriptyline]]
*Amoxapine
*Azatadine
*[[Bupropion]]
*[[Chlorpromazine]]
*Chlorprothixene
*[[Cimetidine]]
*Cisapride
*[[Cocaine]]
*Clomipramine
*[[Clozapine]]
*Cyclizine
*[[Dextromethorphan]]
*[[Diazepam]]
*[[Diphenhydramine]]
*[[Doxepin]]
*[[Etomidate]]
*[[Fluoxetine]]
*Fluphenazine
*Fluvoxamine
*[[Haloperidol]]
*Imipramine
*[[Ketamine]]
*Lozapine
*Mesoridazine
*[[Methohexital]]
*[[Metoclopramide]]
*[[Olanzapine]]
*Paroxetine
*Perphenazine
*Phenelzine
*[[Phenytoin]]
*Pimozide
*[[Prochlorperazine]]
*Promazine
*[[Promethazine]]
*[[Propofol]]
*[[Quetiapine]]
*[[Ranitidine]]
*[[Risperidone]]
*Sertraline
*Thiethylperazine
*[[Thiopental]]
*Thioridazine
*Thiothixene
*Tigabine
*Tranylcypromine
*Trifluoperazine
*Triflupromazine


==DDx==
==Clinical Features==
* tetanus
[[File:Dystonia2010.jpg|thumb|Medication-induced dystonia.]]
* hysterical conversion disorder
*History of recent drug exposure or increase in drug dosage (e.g. prescription, over the counter, herbals, illegal)
* dislocation of mandible
*Dystonia of any striated muscle group:
* electrolyte abnormality (Calcium, magnesium)
**[[Torticollar reaction]] -> twisted neck or facial muscle spasm
* meningitis
**Buccolingual reaction -> protruding or pulling sensation of the tongue
* seizure disorder
**Oculogyric crisis -> roving or deviated gaze
* strychnine poisoning
**Promandibular dystonia
* akathisia
**Lingual dystonia
* stroke
**Opisthotonic -> severe hyperextension of entire spinal column
* drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)
**Kyphosis/lordosis/scoliosis
**Trismus
**Facial grimacing
**Tortipelvic crisis -> abdominal rigidity and pain


==Treatment==
==Differential Diagnosis==
* Anticholinergic medication:  
{{Movement disorder DDX}}
* Diphenhydramine: 50-100mg over 2 minutes
{{Jaw spasms DDX}}
* Benztropine: 1-2 mg in adults over 2 minutes
{{Neck pain DDX}}
* Biperiden
 
* Trihexyphenidyl 2mg PO BID
==Evaluation==
* IV > IM > PO
*Normally a clinical diagnosis
* 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)
*Consider [[urine toxicology]] if no offending agent given by history
* patients may require more than one dose of IV medication before symptoms resolve completely
*More chronic neurologic side effects of phenothiazines (akathisia, tardive dyskinesia, parkinsonism) don't usually respond as dramatically to treatment as does acute dystonia
* Benzodiazepines  
 
* Airway Management
==Management==
* rare, but may be indicated in patients with severe respiratory distress from laryngeal or pharyngeal dystoni
*[[Anticholinergic]] medication:  
**[[Benztropine]]: 1-2mg in adults over 2 minutes
**[[Diphenhydramine]]: 25-50mg 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 dystonia


==Disposition==
==Disposition==
* stop the offending agent (if antipsychotic, speak with patients psychiatrist before just stopping the medication)
*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  
*Continue to treat with PO anticholinergic to prevent relapse of symptoms (if the culprit is long acting)
* Diphenhydramine: 12.5-50mg PO TID-QID
**[[Benztropine]]: 1-2mg PO BID during 2-3 days
* Benztropine: 1-2mg PO BID
**[[Diphenhydramine]]: 25mg PO QID for 24-72 hours


==Source==
==See Also==
Adapted from Harwood-Nuss
*[[Torticollis]]
*[[Extrapyramidal reaction]]


emedicine
==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:Psych]]
[[Category:ENT]]
[[Category:Tox]]
[[Category:Neurology]]
[[Category:Psychiatry]]
[[Category:Toxicology]]

Latest revision as of 20:07, 12 May 2022

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
  • Dystonia is idiosyncratic (not dose-related)

Predisposing Factors

  • Young age
  • Family history of dystonic reaction
  • History of EtOH or drug use
  • Associated with administration of antiemetics or antipsychotic medications (in 10-60% of treated patients)
  • 25% of patients treated with haloperidol 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

Medications Associated with Dystonic Reaction

Clinical Features

Medication-induced dystonia.
  • 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 -> twisted neck or facial muscle spasm
    • Buccolingual reaction -> protruding or pulling sensation of the tongue
    • Oculogyric crisis -> roving or deviated gaze
    • Promandibular dystonia
    • Lingual dystonia
    • Opisthotonic -> severe hyperextension of entire spinal column
    • Kyphosis/lordosis/scoliosis
    • Trismus
    • Facial grimacing
    • Tortipelvic crisis -> abdominal rigidity and pain

Differential Diagnosis

Movement Disorders and Other Abnormal Contractions

Jaw Spasms

Neck pain

Evaluation

  • Normally a clinical diagnosis
  • Consider urine toxicology if no offending agent given by history
  • More chronic neurologic side effects of phenothiazines (akathisia, tardive dyskinesia, parkinsonism) don't usually respond as dramatically to treatment as does acute dystonia

Management

  • Anticholinergic medication:
    • Benztropine: 1-2mg in adults over 2 minutes
    • Diphenhydramine: 25-50mg 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 dystonia

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 (if the culprit is long acting)

See Also

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.
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