Dystonic reaction: Difference between revisions

No edit summary
No edit summary
Line 3: Line 3:
* rarely life threatening but patient is in distress from pain and discomfort
* rarely life threatening but patient is in distress from pain and discomfort
* men are affected more frequently than women  
* men are affected more frequently than women  
* predisposing factors:
 
* young age
===Predisposing Factors===
* family history of dystonic reaction
# young age
* history of EtOH or drug use  
# family history of dystonic reaction
* associated with administration of antiemetics or antipsychotic medications  
# history of EtOH or drug use  
* 25% of patients treated with Haldol have been known to develop this reaction
# associated with administration of antiemetics or antipsychotic medications  
* reaction usually occurs within 48 hrs of drug treatment but can occur up to 5 days after starting therapy  
# 25% of patients treated with Haldol have been known to develop this reaction
* severity and onset of reaction depends on an individual, no association with dose, drug type, potency of drug, or duration of treatment  
# reaction usually occurs within 48 hrs of drug treatment but can occur up to 5 days after starting therapy  
* many theories on what causes the reaction
# severity and onset of reaction depends on an individual, no association with dose, drug type, potency of drug, or duration of treatment  
* 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==
==Diagnosis==
* History of recent drug exposure or increase in drug dosage
* History of recent drug exposure or increase in drug dosage
* Thorough drug history (prescription, over the counter, herbals, illegal)  
* 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
# 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  
* oromandibular dystonia
## oculogyric crisis
* lingual dystonia
## oromandibular 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==
Line 85: Line 83:


==DDx==
==DDx==
* 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==
* Anticholinergic medication:  
# Anticholinergic medication:  
* Diphenhydramine: 50-100mg over 2 minutes
## Diphenhydramine: 50-100mg over 2 minutes
* Benztropine: 1-2 mg in adults over 2 minutes
## Benztropine: 1-2 mg 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==
* 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  
* Diphenhydramine: 12.5-50mg PO TID-QID
## Diphenhydramine: 12.5-50mg PO TID-QID
* Benztropine: 1-2mg PO BID  
## Benztropine: 1-2mg PO BID  


==Source==
==Source==

Revision as of 23:04, 11 June 2011

Background

  • adverse extrapyramidal effect (intermittent spasmodic or sustained involuntary contractions of muscles) that occurs shortly after initiation of new drugs
  • rarely life threatening but patient is in distress from pain and discomfort
  • men are affected more frequently than women

Predisposing Factors

  1. young age
  2. family history of dystonic reaction
  3. history of EtOH or drug use
  4. associated with administration of antiemetics or antipsychotic medications
  5. 25% of patients treated with Haldol have been known to develop this reaction
  6. reaction usually occurs within 48 hrs of drug treatment but can occur up to 5 days after starting therapy
  7. 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)
  1. Physical exam is usually normal except for dystonia of any striated muscle group. Some common presentations include:
    1. torticollar reaction
    2. buccolingual reaction
    3. oculogyric crisis
    4. oromandibular dystonia
    5. lingual dystonia
    6. kyphosis/lordosis/scoliosis
    7. trismus
    8. facial grimacing
    9. 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 Utox if no offending agent given by history

DDx

  1. tetanus
  2. hysterical conversion disorder
  3. dislocation of mandible
  4. electrolyte abnormality (Calcium, magnesium)
  5. meningitis
  6. seizure disorder
  7. strychnine poisoning
  8. akathisia
  9. stroke
  10. drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)

Treatment

  1. Anticholinergic medication:
    1. Diphenhydramine: 50-100mg over 2 minutes
    2. Benztropine: 1-2 mg in adults over 2 minutes
    3. Biperiden
    4. Trihexyphenidyl 2mg PO BID
    5. IV > IM > PO
    6. 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)
    7. patients may require more than one dose of IV medication before symptoms resolve completely
  2. Benzodiazepines
  3. Airway Management
    1. rare, but may be indicated in patients with severe respiratory distress from laryngeal or pharyngeal dystoni

Disposition

  1. stop the offending agent (if antipsychotic, speak with patients psychiatrist before just stopping the medication)
  2. continue to treat with PO anticholinergic to prevent relapse of symptoms
    1. Diphenhydramine: 12.5-50mg PO TID-QID
    2. Benztropine: 1-2mg PO BID

Source

Adapted from Harwood-Nuss

emedicine

Retrieved from "https://www.wikem.org/w/index.php?title=Dystonic_reaction&oldid=2828"