NMS Flashcards
Managements
The candidate should be able to show his awareness of serious complications like NMS arising in the context of acute psychiatric presentations. The candidate should proceed with further physical examination (especially focus on neurological examination like rigidity, focal neurological deficits etc) and investigations (CK, liver enzymes, urine myoglobinuria, serial full blood count etc.) needed to diagnose, differentiate and manage such complications. Such complications though rare (0.02 to 3 percent) can have mortality rate of 10 to 20 percent. The candidate should be able to recognise high dose of parenteral higher potency typical neuroleptic use as a major risk factor for developing in this vignette. In addition to NMS the candidate should also consider other diagnosis like delirium, systemic infections, sexually transmitted diseases, malignant catatonia etc.
The candidate should be able to show expertise in dealing with NMS, which needs collaborative work with the medical team. The candidate should be able to raise practical issues emerging in dealing with these types of situations like difficulty in managing an agitated psychiatric patient on a medical ward or Intensive Care Unit, disruption of the ward atmosphere, taking lead in supporting the medical team like requesting a psychiatric nurse watch, involving consultation-liaison psychiatric department, talking to the family etc. The candidate should have a basic knowledge of the principles of treatment of NMS which includes stopping of antipsychotics and issues with that, alternatives like benzodiazepines but that carry risk of sedation or more disorientation, supportive treatment like re-hydration, restoring electrolyte imbalance, monitoring of vitals signs (pulse, temperature, blood pressure, respiratory rate) etc and definitive treatments (dantrolene, use of dopamine agonists like bromocriptine or amantadine).
The candidate then is expected to consider pharmacological (continuation of mood stabiliser, re-challenging with antipsychotics) and non-pharmacological (ECT) interventions in this patient. The candidate should be able to talk about the risks associated with the interventions like delaying treating psychotic element by using only mood stabilisers and risk of further NMS/increased mortality with rechallenge with antipsychotics. The candidate should talk about specific risks with ECT like uncontrolled seizure/status epilepticus, cardiovascular complications like ventricular fibrillation and cardiac arrest with permanent anoxic brain injury, aspiration pneumonia, anaesthesia related like succinylcholine related hyperthermia, autonomic dysfunctions etc. The candidate is expected to raise issue of consent in a person under MHA which might need second opinion based on local mental health legislation.
Examination
The candidate should describe appropriate and relevant physical examination like complete checking of hydration status, serial blood pressure, pulse rate, temperature, respiratory rate etc, neurological examination with special reference to rigidity (neck or limb), and rash etc. Focus should also be on a brief cognitive assessment to rule out delirium.
Investigation
.The candidate should look into investigations as per differential diagnosis, like for NMS repeat white blood count, blood culture for systemic infections, serial CK levels of 1000 IU/L or more, elevation of liver enzymes (lactate dehydrogenase, alkaline phosphatase and transaminases), electrolyte disturbances, urine for myoglobin etc. Lumbar puncture, radiological investigations like CT/MRI scan for any intracranial infections. Urine infection and STD related investigations should be considered like urine culture and sensitivity, VDRL serology etc.
Diagnosis
.The candidate considers NMS/delirium first due to the history of rapid dose escalation with typical high potency antipsychotic; and the current presentation of altered sensorium with autonomic instability. The candidate should be able to consider other diagnosis like malignant catatonia, meningitis or encephalitis, systemic manifestations of sexually transmitted diseases or urinary tract infections.
Management
.The candidate takes NMS very seriously and looks into stopping of antipsychotics; shows urgency in dealing with the possibility of severe, even fatal complications like dehydration, electrolyte imbalance, acute renal failure associated with rhabdomyolysis, cardiac arrhythmias, seizures or sepsis, DVT etc. The difficulty of dealing with such medical complications on a psychiatric ward would mean liaison with the medical/Intensive Care Unit professionals for transfer of the patient, where supportive and specific treatments can be provided while monitoring physical state. The candidate is expected to outline knowledge of basic supportive treatment like monitoring vitals, intravenous fluids and specific treatments like dantrolene, bromocriptine or amantadine (dose related detail are not required). The candidate makes attempt to inform the patient’s family about the clinical progress.The candidate shows good knowledge base of pharmacological (re-challenge with antipsychotics, continuation of sodium mood stabilisers) and non-pharmacological options (ECT). The candidate should be able to discuss issues around rechallenging with antipsychotics and ECT, which is also recommended through the College guidelines. The candidate should be able to discuss safety concerns with ECT requiring anaesthetic evaluation in NMS like cardiac complications (fibrillation, cardiac arrest), uncontrolled seizures, aspiration pneumonia, and risks of hyperthermia with depolarising anaesthetic agents like succinylcholine.
