Dystonic reaction: Difference between revisions
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* Consider Urine Tox if no offending agent given by history | * Consider Urine Tox if no offending agent given by history | ||
== | ==Differential Diagnosis== | ||
*Tetanus | *[[Tetanus]] | ||
*Hysterical conversion disorder | *Hysterical [[conversion disorder]] | ||
*Dislocation of mandible | *[[Dislocation of mandible]] | ||
*Electrolyte abnormality (Calcium, magnesium) | *[[Electrolyte abnormality]] (Calcium, magnesium) | ||
*Meningitis | *[[Meningitis]] | ||
*Seizure disorder | *[[Seizure]] disorder | ||
*Strychnine poisoning | *[[Strychnine]] poisoning | ||
*Akathisia | *Akathisia | ||
*Stroke | *[[Stroke]] | ||
*Drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine) | *[[Drug toxicity]] (anticholinergic, phenytoin, valproate, carbamazepine) | ||
==Treatment== | ==Treatment== | ||
Revision as of 23:46, 15 February 2015
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
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
- 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
Work-Up
- Consider Urine Tox if no offending agent given by history
Differential Diagnosis
- Tetanus
- Hysterical conversion disorder
- Dislocation of mandible
- Electrolyte abnormality (Calcium, magnesium)
- Meningitis
- Seizure disorder
- Strychnine poisoning
- Akathisia
- Stroke
- Drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)
Treatment
- Anticholinergic medication:
- Diphenhydramine: 50-100mg over 2 minutes
- Benztropine: 1-2 mg 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
Source
- Adapted from Harwood-Nuss
- Emedicine
- 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.