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1.06 Dystonic Drug Reaction


Presentation

Patients arrive with peculiar posturing or difficulty speaking, and are usually quite upset and worried that they are having a stroke. Often there is no history offered at all--the patient may not be able to speak, may not be aware he took any phenothiazines or butyrophenones (e.g., Haldol has been used to cut heroin), may not admit he takes psychotropic medication, or may not make the connection between symptoms and drug (e.g., one dose of Compazine given for vomiting). Acute dystonias usually present with one or more of the following symptoms: These acute dystonias can resemble partial seizures, the posturing of psychosis, or the spasms of tetanus, strychnine poisoning, or electrolyte imbalances. More chronic neurologic side effects of phenothiazines, including the restlessness of akathisia, tardive dyskinesias, and Parkinsonism, do not usually respond as dramatically to drug treatment as the acute dystonias.

What to do:

What not to do:

Discussion

The extrapyramidal motor system depends on excitatory cholinergic neurotransmitters and inhibitory dopaminergic neurotransmittors, the latter susceptible to blockage by phenothiazine and butyrophenone medications. Anticholinergic medications restore the excitatory-inhibitory balance. One intravenous dose of benztropine or diphenhydramine is relatively innocuous and rapidly diagnostic, and is probably justified as an initial step in any patient with a dystonic reaction.

References:


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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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Craig Feied, MD
Mark Smith, MD
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