Dystonic reaction: Difference between revisions

(grammar, citation, link added)
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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
* Men > Women


===Predisposing Factors===
===Predisposing Factors===
# young age
# Young age
# family history of dystonic reaction
# Family history of dystonic reaction
# history of EtOH or drug use  
# History of EtOH or drug use  
# associated with administration of antiemetics or antipsychotic medications  
# 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  
# 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  
# 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
## Torticollar reaction
## buccolingual reaction  
## Buccolingual reaction  
## oculogyric crisis
## Oculogyric crisis
## oromandibular dystonia
## Promandibular dystonia
## lingual dystonia
## Lingual dystonia
## kyphosis/lordosis/scoliosis  
## Kyphosis/lordosis/scoliosis  
## trismus
## Trismus
## facial grimacing
## Facial grimacing
## tortipelvic crisis  
## Tortipelvic crisis  


==Medications Associated with Dystonic Reaction==
==Medications Associated with Dystonic Reaction==
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==Work-Up==
==Work-Up==
* consider Utox if no offending agent given by history
* Consider Urine Tox if no offending agent given by history


==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==
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## 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
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==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==
Adapted from Harwood-Nuss
*Adapted from Harwood-Nuss
 
*Emedicine
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

  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. Promandibular 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 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

  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

  • 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.