Dystonic reaction: Difference between revisions
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==Background== | ==Background== | ||
* Adverse extrapyramidal effect shortly after initiation of new drugs | *Adverse extrapyramidal effect shortly after initiation of new drugs | ||
**intermittent spasmodic or sustained involuntary contractions of muscles | **intermittent spasmodic or sustained involuntary contractions of muscles | ||
* 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 > Women | *Men > Women | ||
===Predisposing Factors=== | ===Predisposing Factors=== | ||
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==Medications Associated with Dystonic Reaction== | ==Medications Associated with Dystonic Reaction== | ||
* Amitriptyline | *Amitriptyline | ||
* Amoxaine | *Amoxaine | ||
* Azatadine | *Azatadine | ||
* Buproprion | *Buproprion | ||
* Chlorpromazine | *Chlorpromazine | ||
* Chlorprothixene | *Chlorprothixene | ||
* Cimetiddine | *Cimetiddine | ||
* Cisapride | *Cisapride | ||
* Cocaine | *Cocaine | ||
* Clomipramine | *Clomipramine | ||
* Clozapine | *Clozapine | ||
* Cyclizine | *Cyclizine | ||
* Dexgtromethorphan | *Dexgtromethorphan | ||
* Diazepam | *Diazepam | ||
* Diphenhydramine | *Diphenhydramine | ||
* Doxepin | *Doxepin | ||
* Etomidate | *Etomidate | ||
* Fluoxetine | *Fluoxetine | ||
* Fluphenazine | *Fluphenazine | ||
* Fluvoxamine | *Fluvoxamine | ||
* Haloperidol | *Haloperidol | ||
* Imipramine | *Imipramine | ||
* Ketamine | *Ketamine | ||
* Lozapine | *Lozapine | ||
* Mesoridazine | *Mesoridazine | ||
* Methohexital | *Methohexital | ||
* Metoclopraminde | *Metoclopraminde | ||
* Olanzpine | *Olanzpine | ||
* Paroxetine | *Paroxetine | ||
* Perphenazine | *Perphenazine | ||
* Phenelzine | *Phenelzine | ||
* Pheyntoin | *Pheyntoin | ||
* Pimozide | *Pimozide | ||
* Prochlorperazine | *Prochlorperazine | ||
* Promazine | *Promazine | ||
* Promethazine | *Promethazine | ||
* Propofol | *Propofol | ||
* Quietiapine | *Quietiapine | ||
* ranitidine | *ranitidine | ||
* Risperidone | *Risperidone | ||
* Sertraline | *Sertraline | ||
* Thiethylperazine | *Thiethylperazine | ||
* Thiopental | *Thiopental | ||
* Thioridazine | *Thioridazine | ||
* Thiothixene | *Thiothixene | ||
* Tigabine | *Tigabine | ||
* tranylcypromine | *tranylcypromine | ||
* Trifluoperazine | *Trifluoperazine | ||
* Triflupromazine | *Triflupromazine | ||
==Work-Up== | ==Work-Up== | ||
* Consider Urine Tox if no offending agent given by history | *Consider Urine Tox if no offending agent given by history | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Revision as of 19:37, 4 July 2016
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
Jaw Spasms
- Acute tetanus
- Akathisia
- Conversion disorder
- Drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)
- Dystonic reaction
- Electrolyte abnormality
- Hypocalcemic tetany
- Magnesium
- Mandible dislocation
- Meningitis
- Peritonsillar abscess
- Rabies
- Seizure
- Strychnine poisoning
- Stroke
- Temporomandibular disorder
- Torticollis
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
References
- 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.