toxidromes

Question 1

NMS 2 core criteria

DSM criteria

Answer 1

hyperthermia
rigidity
The development of severe muscle rigidity and elevated temperature associated with the use of antipsychotic medication.

Two (or more) of the following:

1. diaphoresis
2. dysphagia
3. tremor
4. incontinence
5. changes in level of consciousness ranging from confusion to coma
6. mutism
7. tachycardia
8. elevated or labile blood pressure
9. leucocytosis
10. laboratory evidence of muscle injury (e.g., elevated CK)

The symptoms in Criteria A and B are not due to another substance (e.g., phencyclidine) or a neurological or other general medical condition (e.g., viral encephalitis).

The symptoms in Criteria A and B are not better accounted for by a mental disorder (e.g., Mood Disorder with Catatonic Features).

Question 2

clozapine

Answer 2

i. the signs of clozapine toxicity include: tachycardia, hypotension, lethargy/drowsiness, constipation, vomiting, seizures, agitation, delirium, mydriasis, diplopia, hyperreflexia

Question 3

carbamaz

Answer 3

i. side effects of carbamazepine include a rash, hyponatremia, hematopoietic alterations, peripheral neuropathy, and liver toxicity; benign transient neutropenia occurs in 20% of patients; agranulocytosis is rare; 3% of patients taking carbamazepine develop a hypersensitivity reaction consisting of a rash (erythema multiforme) and a fever – carbamazepine should be discontinued in such instances

Question 4

TCA

Answer 4

i. the main signs of TCA toxicity are anticholinergic signs, cardiac signs, and neurological signs
ii. anticholinergic signs: blurred vision (mydriasis or pupillary dilation), fever, dry mouth, tachycardia, urinary retention, ileus, delirium (think: blind as a bat, dry as a bone, hot as Hades, mad as a hatter)
iii. cardiac toxicity: tachycardia, hypotension, ECG changes, arrhythmias
iv. neurological signs: confusion, myoclonus, seizures, coma

Question 5

clonidine

Answer 5

i. clonidine is an alpha-2 agonist; works by reducing adrenergic tone; it may cause dry mouth, sedation, weakness, hypotension, irritability, impotence; weight gain can happen but is less common. Sz is not a side effect but can happen in OD. OD looks like opiod OD

Question 6

Tx of NDI (Li)

Answer 6

i. nephrogenic diabetes inspidus can be treated with indomethacin, sodium restriction, thiazide diuretics; lithium induced polyuria should be treated with amiloride or ddAVP; possibly with NSAIDs

Question 7

Li

Answer 7

i. normal blood levels: polydipsia, polyuria, dry mouth, weight gain, fatigue
ii. occasional side effects: metallic taste, nausea/diarrhea, fine tremor, edema
iii. less occasional side effects: hypothyroidism, hypokalemia, EKG changes, mental slowness, worsening of psoriasis, kidney changes, raised levels of ADH, goiter
iv. mild toxicity: blurred vision, weakness, worsening GI side effects, CNS disturbances (coarse tremor, ataxia, dysarthria, nystagmus)
v. severe toxicity: hyperreflexia, convulsions, psychosis, syncope, oliguria, circulatory failure, coma

Question 8

effects of blocking receptors

Answer 8

i. anti muscarinic anticholinergic effects include: blurred vision (mydriasis or pupillary dilation), fever, dry mouth, tachycardia, urinary retention, ileus, delirium (think: blind as a bat, dry as a bone, hot as Hades, mad as a hatter); muscarinic receptors are also involved in the modulation of erection and ejaculation/orgasm
ii. anti histaminic: sedation and weight gain
iii. anti-alpha-1 adrenergic: orthostatic hypotension, dizziness, drowsiness, priapism
iv. anti beta-adrenergic: erectile dysfunction
v. blocking 5-HT-2: agitation, akathisia, anxiety, insomnia, sexual function (delayed ejaculation or orgasm)
vi. blocking 5-HT-3: nausea, diarrhea, emesis, migraine pain

Question 9

tx of akathesia

Answer 9

• Most effective are beta blockers

* Anticholinergics, benzodiazepines, and cyproheptadine can also work