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Dystonic Reaction, Emergency Medicine

Basics

Description

- Risk factors: - Children and young adults are at higher risk - Rarely occurs in patients over 45 yr of age - Males more often affected - Prior episodes of dystonia significantly increase risk - Recent cocaine use increases risk

- Characteristic involuntary muscle spasms occur - Oculogyric crisis - Involves eye and periorbital muscles - Evolves into painful upward or lateral deviation of the eyes

- Buccolingual crisis - Involves facial muscles and the tongue - May have difficulty speaking - Facial grimacing - Trismus - Tongue protrusion - Dysphagia

- Opisthotonos - Involves muscles of trunk and back - Twisting and arching of spine

- Seizure: - History of prior seizures - Not responsive to verbal stimuli - Tonic-clonic-type motor movements rather than spasm

- Administer diphenhydramine (Benadryl) or benztropine mesylate (Cogentin): - Rapid resolution of muscular spasm by restoring cholinergic-dopaminergic balance in CNS - IV administration is preferred route of treatment - Onset of relief in 2-5 min - Complete resolution of symptoms in 30 min - IM administration is alternate route of treatment - Begins to work in 15-30 min - Continue oral administration for 3 days to prevent redevelopment of symptoms

  • Normal pattern of CNS neurotransmission maintained by balance between dopaminergic and cholinergic receptors:Certain drugs antagonize dopamine receptors in the basal ganglia resulting in an imbalance of dopaminergic and cholinergic stimulationThis imbalance leads to acute involuntary muscle spasms of the face or neck (the trunk, pelvis, or extremities can also be affected)
  • Although the spasms are uncomfortable and frightening, they are not life threatening except in very rare cases when laryngeal muscles are involved
  • Usually occurs within hours of ingestion:Almost always within 1st wk after exposure to offending drug
  • Risk factors:Children and young adults are at higher riskRarely occurs in patients over 45 yr of ageMales more often affectedPrior episodes of dystonia significantly increase riskRecent cocaine use increases risk

Etiology

  • Usually occurs after patient has taken antipsychotic, antiemetic, or antidepressant drug
  • Incidence of dystonic reactions varies widely (2-25%) depending on the potency of the agent
  • Higher with more potent drugs (haloperidol, fluphenazine)
  • Lower with less potent drugs (chlorpromazine, thioridazine)
  • Lowest with atypical antipsychotics (quetiapine, olanzapine, risperidone)
  • Antiemetic agents:Metoclopramide (Reglan)Prochlorperazine (Compazine)Promethazine (Phenergan)Droperidol (Inapsine)
  • Other agents:Cyclic antidepressantsH2 blockersSome antimalarial agentsAntihistaminesSome anticonvulsantsDoxepinLithiumPhencyclidine

Children are particularly vulnerable to dystonic reactions when dehydrated or febrile

Diagnosis

Signs and Symptoms

History

  • Ingestion of neuroleptic, antiemetic, or other drug within week of symptom onsetMay occur in patients on neuroleptic agents who increase their dose of neuroleptics or reduce medications (anticholinergic agents) used to treat extrapyramidal symptoms
  • Difficulty with vocalization
  • Completely alert and able to answer questions, although facial muscle involvement may make speech difficult.
  • Involuntary muscle contractions or spasms usually involving the face or neck (see "Physical Exam"):Muscles of the trunk, pelvis, or extremities can also be involved

Physical Exam

  • Characteristic involuntary muscle spasms occur
  • Oculogyric crisisInvolves eye and periorbital musclesEvolves into painful upward or lateral deviation of the eyes
  • BlepharospasmInvoluntary eyelid closure
  • Buccolingual crisisInvolves facial muscles and the tongueMay have difficulty speakingFacial grimacingTrismusTongue protrusionDysphagia
  • Spasmodic torticollis
  • Torticopelvic crisisAbdominal wall muscle spasm
  • OpisthotonosInvolves muscles of trunk and backTwisting and arching of spine
  • Laryngeal dystoniaVery rare but potentially life threateningMay develop airway obstruction due to laryngospasmPresents as dysphonia or stridor

Essential Workup

  • Clinical diagnosis is based on characteristic signs and symptoms with history of possible drug exposure
  • Diagnosis is confirmed by response to treatmentLack of response to treatment should lead one to consider alternative diagnosis

Diagnosis Tests & Interpretation

Lab

  • Lab testing not routinely indicated
  • If no response to treatment, hypocalcemia should be considered and calcium level obtained

Imaging

No imaging studies needed

Differential Diagnosis

  • Tardive dyskinesia:Complication of chronic antipsychotic therapyUsually choreiform movementsDoes not rapidly improve with administration of anticholinergic drug
  • Akathisia:Involuntary motor restlessnessMay appear agitated
  • Seizure:History of prior seizuresNot responsive to verbal stimuliTonic-clonic-type motor movements rather than spasm
  • Hysteria or pseudoseizure:History of precipitating emotional eventTonic-clonic motor activity rather than sustained spasm
  • Tetanus
  • Strychnine poisoning
  • Chronic dystonias:Cerebral palsy, familial choreasUsually history of dystonia is associated with chronic neurologic process
  • Scorpion envenomation:Oculogyric crisis and opisthotonos are common manifestations of scorpion envenomationPatient lacks history of drug exposure.
  • Meningitis and encephalitis may present with atypical seizures that mimic dystonic reaction
  • Mandible dislocation
  • Hypocalcemia

Treatment

Pre-Hospital

  • Rarely life threatening
  • Direct attention toward spasm of larynx and tongue to be sure dystonic reaction is not causing respiratory compromise
  • Ask family and friends about ingestions of antipsychotic medications, antiemetics, and recreational drugs
  • Transport pill bottles

Initial Stabilization/Therapy

Stabilize airway to prevent spasm of larynx or tongue from causing respiratory compromise.

Ed Treatment/Procedures

  • Administer diphenhydramine (Benadryl) or benztropine mesylate (Cogentin):Rapid resolution of muscular spasm by restoring cholinergic-dopaminergic balance in CNSIV administration is preferred route of treatmentOnset of relief in 2-5 minComplete resolution of symptoms in 30 minIM administration is alternate route of treatmentBegins to work in 15-30 minContinue oral administration for 3 days to prevent redevelopment of symptoms
  • Diazepam (Valium):Administer in cases of dystonia unresponsive to adequate doses of anticholinergic medicationsFailure to respond to standard treatment should lead physician to consider other diagnoses

Medication

  • Benztropine mesylate (Cogentin): 1-2 mg either IV (over 2 min) or IM followed by 1-2 mg PO BID for 3 days:Not to be used in children <3 yr oldFor children >3 yr old: 0.02 mg/kg IV (over 2 min) or IM followed by 0.02 mg/kg PO BID for 3 days
  • Diphenhydramine (Benadryl): 1-2 mg/kg up to 100 mg either IV (over 2 min) or IM followed by 25-50 mg (peds: 1-2 mg/kg) PO q6-8h for 3 days, or
  • Diazepam: 5-10 mg IV followed by 5 mg PO q4-6h as necessary for 3 days

First Line

Diphenhydramine (Benadryl)

Second Line

Benztropine mesylate (Cogentin):

  • Not to be used in children <3 yr old
  • Diazepam

Follow-Up

Disposition

Admission Criteria

  • Patients are not admitted unless symptoms do not resolve with treatment, there are concerns about maintaining the airway, or the diagnosis is not certain
  • If the dystonic reaction causes laryngospasm patient should be observed for 12-24 hr after symptoms resolve

Discharge Criteria

  • Discharge after resolution of symptoms
  • The offending agent should be discontinued
  • Patient should not drive or perform tasks that require full alertness while taking sedating medications

Followup Recommendations

Patients should follow-up with the prescribing physician of the causative agent

Pearls and Pitfalls

  • The diagnosis of acute dystonia is made based on the history of ingestion coupled with complete resolution of the symptoms after appropriate treatment
  • 1st line of therapy is diphenhydramine
  • Failure to respond should lead you to consider other diagnoses

Additional Reading

  • Derinoz O, Caglar AA. Drug-induced movement disorders in children at paediatric emergency department: "Dystonia'. Emerg Med J. 2013;30:130-133.
  • Goldfrank LR, Lewin NA, Howland MA, et al. Pathophysiology and clinical manifestations. In: Nelson LS, Lewin NA, Howland MA, et al., eds. Goldfranks Toxicologic Emergencies. 9th ed. New York, NY: McGraw Hill; 2011;9:1007-1010.
  • Sachdev PS. Neuroleptic-induced movement disorders: An overview. Psychiatr Clin North Am. 2005;28:255-274.
  • Vena J, Dufel S, Paige T. Acute olanzapine-induced akathisia and dystonia in a patient discontinued from fluoxetine. J Emerg Med. 2006;30:311-317.
  • Wolfson AB, Hendey GW, Ling LJ, et al., eds. Harwood Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott; 2010.

Codes

ICD9

333.72 Acute dystonia due to drugs

ICD10

  • G24.01 Drug induced subacute dyskinesia
  • G24.02 Drug induced acute dystonia
  • G24.09 Other drug induced dystonia
  • G24.0 Drug induced dystonia

SNOMED

  • 230315008 Drug-induced dystonia (disorder)