Dystonic reaction: Difference between revisions
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==Background== | ==Background== | ||
*Adverse extrapyramidal effect shortly after initiation of new drugs | *Adverse extrapyramidal effect shortly after initiation of new drugs <ref>van Harten PN, Hoek HW, Kahn RS. Acute dystonia induced by drug treatment. BMJ. 1999 Sep 4;319(7210):623-6. PMID 10473482</ref><ref>Jitprapaikulsan J, Srivanitchapoom P. Acute Dystonic Reaction Following General Anesthetic Agent Use. Tremor Other Hyperkinet Mov (N Y). 2017;7:514. PMID 29204316</ref> | ||
**intermittent spasmodic or sustained involuntary contractions of muscles | **intermittent spasmodic or sustained involuntary contractions of muscles | ||
*Rarely life threatening but patient is in distress from pain and discomfort | *Rarely life threatening but patient is in distress from pain and discomfort | ||
*Men > Women | *Men > Women | ||
*Dystonia is idiosyncratic (not dose-related) | |||
===Predisposing Factors=== | ===Predisposing Factors=== | ||
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*Family history of dystonic reaction | *Family history of dystonic reaction | ||
*History of EtOH or drug use | *History of EtOH or drug use | ||
*Associated with administration of [[antiemetics]] or [[antipsychotic]] medications | *Associated with administration of [[antiemetics]] or [[antipsychotic]] medications (in 10-60% of treated patients) | ||
*25% of patients treated with [[ | *25% of patients treated with [[haloperidol]] have been known to develop this reaction | ||
*Reaction usually occurs within 48 hrs of drug treatment but can occur up to 5 days after starting therapy | *Reaction usually occurs within 48 hrs of drug treatment but can occur up to 5 days after starting therapy | ||
*Severity and onset of reaction depends on an individual, no association with dose, drug type, potency of drug, or duration of treatment | *Severity and onset of reaction depends on an individual, no association with dose, drug type, potency of drug, or duration of treatment | ||
===Medications Associated with Dystonic Reaction=== | ===Medications Associated with Dystonic Reaction=== | ||
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*Normally a clinical diagnosis | *Normally a clinical diagnosis | ||
*Consider [[urine toxicology]] if no offending agent given by history | *Consider [[urine toxicology]] if no offending agent given by history | ||
*More chronic neurologic side effects of phenothiazines (akathisia, tardive dyskinesia, parkinsonism) don't usually respond as dramatically to treatment as does acute dystonia | |||
==Management== | ==Management== | ||
*[[Anticholinergic]] medication: | *[[Anticholinergic]] medication: | ||
**[[Benztropine]]: 1-2mg in adults over 2 minutes | **[[Benztropine]]: 1-2mg in adults over 2 minutes | ||
**[[Diphenhydramine]]: 25-50mg over 2 minutes | |||
**[[Biperiden]] | **[[Biperiden]] | ||
**[[Trihexyphenidyl]] 2mg PO BID | **[[Trihexyphenidyl]] 2mg PO BID | ||
**IV > IM > PO | **IV > IM > PO | ||
**Symptoms will typically begin resolving in 2-15 minutes | **Symptoms will typically begin resolving in 2-15 minutes but may take up to 90 minutes to completely abate (depends on route in which medication was given) | ||
**Patients may require more than one dose of IV medication before symptoms resolve completely | **Patients may require more than one dose of IV medication before symptoms resolve completely | ||
*[[Benzodiazepines]] | *[[Benzodiazepines]] | ||
*Airway Management | *Airway Management | ||
**Rare, but may be indicated in patients with severe respiratory distress from laryngeal or pharyngeal | **Rare, but may be indicated in patients with severe respiratory distress from laryngeal or pharyngeal dystonia | ||
==Disposition== | ==Disposition== | ||
*Stop the offending agent (if antipsychotic, speak with patients psychiatrist before just stopping the medication) | *Stop the offending agent (if antipsychotic, speak with patients psychiatrist before just stopping the medication) | ||
*Continue to treat with PO anticholinergic to prevent relapse of symptoms | *Continue to treat with PO anticholinergic to prevent relapse of symptoms (if the culprit is long acting) | ||
** | **[[Benztropine]]: 1-2mg PO BID during 2-3 days | ||
**Benztropine | **[[Diphenhydramine]]: 25mg PO QID for 24-72 hours | ||
==Medication Dosing== | |||
{{MedicationDose | |||
| drug = Benztropine | |||
| dose = 1-2mg IV over 2 min | |||
| route = IV | |||
| context = Anticholinergic, first-line | |||
| indication = Dystonic reaction | |||
| population = Adult | |||
}} | |||
{{MedicationDose | |||
| drug = Diphenhydramine | |||
| dose = 25-50mg IV over 2 min | |||
| route = IV | |||
| context = Anticholinergic, first-line | |||
| indication = Dystonic reaction | |||
| population = Adult | |||
}} | |||
==See Also== | ==See Also== | ||
Latest revision as of 10:44, 22 March 2026
Background
- Adverse extrapyramidal effect shortly after initiation of new drugs [1][2]
- intermittent spasmodic or sustained involuntary contractions of muscles
- Rarely life threatening but patient is in distress from pain and discomfort
- Men > Women
- Dystonia is idiosyncratic (not dose-related)
Predisposing Factors
- Young age
- Family history of dystonic reaction
- History of EtOH or drug use
- Associated with administration of antiemetics or antipsychotic medications (in 10-60% of treated patients)
- 25% of patients treated with haloperidol have been known to develop this reaction
- Reaction usually occurs within 48 hrs of drug treatment but can occur up to 5 days after starting therapy
- Severity and onset of reaction depends on an individual, no association with dose, drug type, potency of drug, or duration of treatment
Medications Associated with Dystonic Reaction
- Amitriptyline
- Amoxapine
- Azatadine
- Bupropion
- Chlorpromazine
- Chlorprothixene
- Cimetidine
- Cisapride
- Cocaine
- Clomipramine
- Clozapine
- Cyclizine
- Dextromethorphan
- Diazepam
- Diphenhydramine
- Doxepin
- Etomidate
- Fluoxetine
- Fluphenazine
- Fluvoxamine
- Haloperidol
- Imipramine
- Ketamine
- Lozapine
- Mesoridazine
- Methohexital
- Metoclopramide
- Olanzapine
- Paroxetine
- Perphenazine
- Phenelzine
- Phenytoin
- Pimozide
- Prochlorperazine
- Promazine
- Promethazine
- Propofol
- Quetiapine
- Ranitidine
- Risperidone
- Sertraline
- Thiethylperazine
- Thiopental
- Thioridazine
- Thiothixene
- Tigabine
- Tranylcypromine
- Trifluoperazine
- Triflupromazine
Clinical Features
- History of recent drug exposure or increase in drug dosage (e.g. prescription, over the counter, herbals, illegal)
- Dystonia of any striated muscle group:
- Torticollar reaction -> twisted neck or facial muscle spasm
- Buccolingual reaction -> protruding or pulling sensation of the tongue
- Oculogyric crisis -> roving or deviated gaze
- Promandibular dystonia
- Lingual dystonia
- Opisthotonic -> severe hyperextension of entire spinal column
- Kyphosis/lordosis/scoliosis
- Trismus
- Facial grimacing
- Tortipelvic crisis -> abdominal rigidity and pain
Differential Diagnosis
Movement Disorders and Other Abnormal Contractions
- Chorea
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Hypocalcemia
- Strychnine toxicity
- Acute tetanus
- Parkinson's disease
- Mono amine oxidase inhibitor toxicity
- Phencyclidine toxicity
- Anti-NMDA receptor encephalitis
- Huntington disease
- Wilson's disease
- CVA
- Schizophrenia
- Psychotic agitation
- Dementia
- Lewy body dementia
- Vascular dementia
- Frontotemporal dementia
- Dystonic reaction
- Extrapyramidal reaction
- Torticollis
- Idiopathic movement disorder
Jaw Spasms
- Acute tetanus
- Akathisia
- Conversion disorder
- Drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)
- Dystonic reaction
- Electrolyte abnormality
- Hypocalcemic tetany
- Magnesium
- Mandible dislocation
- Meningitis
- Peritonsillar abscess
- Rabies
- Seizure
- Strychnine poisoning
- Stroke
- Temporomandibular disorder
- Torticollis
Neck pain
- Musculoskeletal
- Torticollis
- Dystonic reaction
- Cervical spondylosis
- Cervical stenosis
- Cancer
- Epidural abscess
- Vertebral osteomyelitis
- Transverse myelitis
- Temporal arteritis
- Epidural hematoma (anticoagulation, hemophilia)
- Cervical disk herniation
- Blunt neck trauma
- Anterior horn disease
- Cervical fractures and dislocations
- Cervical radiculopathy
Evaluation
- Normally a clinical diagnosis
- Consider urine toxicology if no offending agent given by history
- More chronic neurologic side effects of phenothiazines (akathisia, tardive dyskinesia, parkinsonism) don't usually respond as dramatically to treatment as does acute dystonia
Management
- Anticholinergic medication:
- Benztropine: 1-2mg in adults over 2 minutes
- Diphenhydramine: 25-50mg over 2 minutes
- Biperiden
- Trihexyphenidyl 2mg PO BID
- IV > IM > PO
- Symptoms will typically begin resolving in 2-15 minutes but may take up to 90 minutes to completely abate (depends on route in which medication was given)
- Patients may require more than one dose of IV medication before symptoms resolve completely
- Benzodiazepines
- Airway Management
- Rare, but may be indicated in patients with severe respiratory distress from laryngeal or pharyngeal dystonia
Disposition
- Stop the offending agent (if antipsychotic, speak with patients psychiatrist before just stopping the medication)
- Continue to treat with PO anticholinergic to prevent relapse of symptoms (if the culprit is long acting)
- Benztropine: 1-2mg PO BID during 2-3 days
- Diphenhydramine: 25mg PO QID for 24-72 hours
Medication Dosing
Benztropine 1-2mg IV over 2 min IV Diphenhydramine 25-50mg IV over 2 min IV
See Also
References
- Hockberger RS, Richards JR: Thought Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 110: p 1460-1466.