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Neuroleptic Malignant Syndrome

Understand the pathophysiology, clinical features, risk factors, and management of Neuroleptic Malignant Syndrome. Recognize symptoms like autonomic dysfunction and extrapyramidal features. Learn about the drug therapy and other treatment options available.

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Neuroleptic Malignant Syndrome

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  1. Neuroleptic Malignant Syndrome Recognition, Risk factors and Management

  2. Pathophysiology • Relative lack of dopamine • dopamine receptor blockade • inadequate dopamine production

  3. Pathophysiology • Supporting evidence • neuroleptic drugs block dopamine receptors • occurs with other dopamine blocking drugs • occurs on sudden withdrawal of antiparkinsonian therapy • responds to dopamine agonists

  4. Clinical features • Essential • recent or current therapy with dopamine blocking drug • neuroleptic • other drug eg metoclopramide • recently stopped a dopamine agonist eg L-dopa

  5. Clinical features • Major (all within 24 h) • fever > 37.5oC (no other cause) • autonomic dysfunction • extrapyramidal features

  6. Autonomic dysfunction • 2 or more of • hypertension or labile BP • systolic > 30 mmHg above baseline or • diastolic > 20 mmHg above baseline • variability of > 30 mmHg systolic or >20 mmHg diastolic between readings • tachycardia (pulse > 30 bpm above baseline) • diaphoresis (intense) • incontinence • tachypnoea (> 25 breaths/min)

  7. Extrapyramidal features • 2 or more of • bradykinesia • lead-pipe or cogwheel rigidity • resting tremor • sialorrhoea • dysphagia • dysarthria/mutism

  8. Minor features • Support but are not required for diagnosis • rise in creatinine kinase • altered sensorium/delirium • leucocytosis > 15,000x109/L • low serum iron • Help confirm diagnosis • therapeutic response to dopamine agonist

  9. Risk factors • Incidence 1% (0.02–3.23) • Pre-NMS • psychomotor agitation • dehydration

  10. Risk factors • Related to treatment • neuroleptic dose in first 24h > 600 mg of chlorpromazine • maximum dose in any 24h > 600 mg of chlorpromazine • required restraint or seclusion • Associated • past ECT

  11. Management • High risk patients • monitor temperature tds • monitor blood pressure tds • record episodes of diaphoresis • On suspicion • assess for other medical illness • FBC, MBA, CK, serum iron • On diagnosis • withdraw all dopamine blocking drugs

  12. Drug therapy • Bromocriptine • 2.5 mg q8h up to 5 mg q4h • continue for 7–10 days after resolution then taper over 1–2 weeks (except depot preparations) • Dantrolene • 2–3 mg/kg • extreme rigidity, very high fever (> 40oC), unable to tolerate oral treatment

  13. Other therapy • Benzodiazepines • to control agitation/delirium • ECT • refractory to adequate trial of dopamine agonist/supportive care • after resolution of acute features • remain catatonic or • develop ECT-responsive psychotic features • suspected acute lethal catatonia

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