Dystonic reaction: Difference between revisions
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==Background== | ==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=== | ===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 | # 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== | ==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: | #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== | ==Medications Associated with Dystonic Reaction== | ||
Line 80: | Line 81: | ||
==Work-Up== | ==Work-Up== | ||
* | * Consider Urine Tox if no offending agent given by history | ||
==DDx== | ==DDx== | ||
*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== | ==Treatment== | ||
Line 101: | Line 102: | ||
## 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) | ||
## | ## Patients may require more than one dose of IV medication before symptoms resolve completely | ||
# Benzodiazepines | # Benzodiazepines | ||
# Airway Management | # Airway Management | ||
Line 108: | Line 109: | ||
==Disposition== | ==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== | ==Source== | ||
Adapted from Harwood-Nuss | *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. | |||
[[Category:ENT]] | [[Category:ENT]] | ||
[[Category:Neuro]] | |||
[[Category:Psych]] | [[Category:Psych]] | ||
[[Category:Tox]] | [[Category:Tox]] |
Revision as of 02:32, 4 January 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
DDx
- 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.