Neuroleptic malignant syndrome Flashcards

1
Q

Define neuroleptic malignant syndrome.

A

Acute potentially life threatening complication or antipsychotic/dopamine antagonist treatment or acute withdrawal of it

A disorder of thermoregulation and neuromotor control

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2
Q

How common is NMS?

A

<1% of patients taking antipsychotics affected

Has declined over last 20yrs which may be due to greater awareness or more second-generation antipsychotic use

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3
Q

What is the pathophysiology of NMS?

A

Not well established - acute imbalance or dysregulation of CNS neurotransmitters is strongly suspected

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4
Q

What are the risk factors for NMS?

A
  • High dose typical antipsychotics - usually within 3-9 days of starting treatment; has been reported with antidepressants but less common
  • Rapid dose changes or withdrawal
  • Male gender
  • Older age
  • Pre-existing brain abnormality e.g. dementia, trauma, Wilson’s, PD.
  • Dehydration
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5
Q

What are the clinical features of NMS?

A
  • Muscle rigidity
  • Hyperthermia
  • Hyporeflexia
  • Diaphoresis, urinary incontinence
  • Autonomic dysregulation e.g. tachycardia, hypotension
  • Altered consciousness - confusion, delirium, stupor
  • Hypermetabolism
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6
Q

How do you diagnose NMS?

A
  • Raised CK - typically >1000
  • Raised WCC
  • Deranged LFTs - may get liver failure
  • Deranged renal function (due to rhabdo from raised CK) - e.g. myoglobinuria, hyperkalaemia, hyper/hyponatraemia

Other:
* ECG - long PR, QRS, QT; ST or T wave abnormalities
* CT scan - exclude brain abnormality
* Urine/blood culture
* CXR - increased risk of aspiration

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7
Q

What is the management of NMS?

A
  • Stop causative agent + transfer to ITU
  • Support care:
  • Fluids - treat the rhabdomyolysis, consider urine alkalinisation
  • Cooling - treat hyperthermia
  • Sedation with benzodiazepines - relax muscles and manage agitation
  • Bromocriptine (DA) or Dantrolene - muscle relaxant if no response to supportive treatment to treat hyperthermia and rigidity

Other:
* ECT - case reports; may further elevate CK

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8
Q

When can antipsychotics be started again after NMS?

A

Wait at least 2 weeks after NMS

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9
Q

What are some signs of severe NMS requiring critical care?

A

Moderate/severe NMS
Severe hyperthermia >38.5C despite cooling
Coma
Compromised ventilation
Acute renal failure or severe hyperkalaemia

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10
Q

What is the classification of severity of NMS?

A
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11
Q

What are the complications of NMS?

A
  • Sepsis
  • AKI
  • Status epilepticus
  • Rhabdomyolysis
  • PE - due to immobility
  • Aspiration
  • Cognitive deficits
  • Worsening psychosis
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12
Q

What is the prognosis with NMS?

A

Mortality varies - studies report 8-9%
Recurrence is as high as 30%

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