Class 5 Flashcards
Neuroleptic malignant syndrome def and incidence, usually happens in
is a life-threatening neurologic emergency associated with the use of antipsychotic (neuroleptic) agents.
Incidence rates for NMS range from 0.02 to 3 percent among patients taking antipsychotic agents. Usually during 2 first weeks of treatment.
NMS symptoms
The tetrad of NMS symptoms typically evolves over one to three days. Each feature is present in 97 to 100 percent of patients:
●Mental status change is the initial symptom in 82 percent of patients. It is not surprising, given the usual psychiatric comorbidity of the typical patient, that its significance is often underappreciated. This often takes the form of an agitated delirium with confusion rather than psychosis. Catatonic signs and mutism can be prominent. Evolution to profound encephalopathy with stupor and eventual coma is typical.
●Muscular rigidity is generalized and is often extreme. The increased tone can be demonstrated by moving the extremities and is characterized by “lead-pipe rigidity” or stable resistance through all ranges of movement. Superimposed tremor may lead to a ratcheting quality or a cogwheel phenomenon. Other motor abnormalities include tremor (seen in 45 to 92 percent), and less commonly, dystonia, opisthotonus, trismus, chorea, and other dyskinesias. Patients can also have prominent sialorrhea, dysarthria, and dysphagia.
●Hyperthermia is a defining symptom according to many diagnostic criteria. Temperatures of more than 38°C are typical (87 percent), but even higher temperatures, greater than 40°C, are common (40 percent). Fever may be a less consistent symptom in patients with NMS associated with second-generation antipsychotic agents.
●Autonomic instability typically takes the form of tachycardia (in 88 percent), labile or high blood pressure (in 61 to 77 percent), and tachypnea (in 73 percent). Dysrhythmias may occur. Diaphoresis is often profuse.
Elevated serum CK. More than 1000.
Risk factors: NMS
increased doses, increases ambient temperature, intellectual handicap, traumatic brain injury.
Treatment:
NMS
Discontinue any antipsychotic agent or precipitating drug.
●Maintain cardiorespiratory stability. Mechanic ventilation, antiarrhythmic agents, or pacemakers may be required.
●Maintain euvolemic state using intravenous fluids. Insensible fluid loss from fever and from diaphoresis should also be considered. If creatine kinase (CK) is very elevated, high-volume intravenous fluids with urine alkalinization may help prevent or mitigate renal failure from rhabdomyolysis.
●Lower fever using cooling blankets. More aggressive physical measures may be required: ice water gastric lavage and ice packs in the axilla. The use ofacetaminophenoraspirinmay have a role in reducing temperature in NMS, but it is not established.
●Lower blood pressure if markedly elevated. The use of any specific agent over another is not supported by clinical data.Clonidine is effective in this setting.Nitroprussidemay have advantages by also facilitating cooling through cutaneous vasodilation.
●Prescribe heparin or low molecular weight heparin for prevention of deep venous thrombosis.
●Use benzodiazepines (eg,lorazepam0.5 to 1 mg) to control agitation, if necessary.
●Muscle relaxants
Prescribe lurasidone
: Oral:Initial: 40 mg once daily in the evening within 30 minutes of food (≥350 calories); may increase daily dose based on response and tolerability in increments of 40 mg every ≥3 days to a maximum dose of 160 mg/day; usual dose: 40 to 80 mg/day.
S/E lurasidone
Novo, SEP
Lurasidone and lithium:
Lithium may enhance the neurotoxic effect of Antipsychotic Agents. Lithium may decrease the serum concentration of Antipsychotic Agents
Loxapine se
Sedation, weight gain, SEP, anticholinergic, hto, tachycardia, constipation, sexual s/e
NMS
Loxapine and seroquel
Anticholinergic Agents may enhance the adverse/toxic effect of other Anticholinergic Agents.(dry mouth, dry eyes, blurred vision, urinary retention, and constipation)
