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MANAGEMENT OF
ANTIPSYCHOTIC
OVERDOSE
Presented by:
Sunil Kumar Daha
ANTIPSYCHOTIC DRUGS
 Inhibition of α-adrenergic receptors
 Inhibition of dopaminergic receptors
 Inhibition of histaminergic receptors
 Inhibition of muscarinic receptors
 Inhibition of serotonergic receptors
 Inhibition sodium, potassium, and
calcium channels
COMMON USES
 Antipsychotic
 Control nausea and vomiting
 Gastro esophageal disorders
SYMPTOMS
 Anti-cholinergic features (tachycardia,
hypertention, confusion, hallucination,
sedation, myoclonus, fever, diplopia,
mydriasis, lleus, palpable bladder,
flushing, dry mouth
 Serotogenic features (tachycardia, <-
>BP, confusion, hallucination, sedation,
coma, shivering, myoclonus, fever,
diarrhea, comitting, flushing)
 Prolonged QT interval, torsades de
HYPERKINETIC MOVEMENT
DISORDER
 Acute
 Sub acute
 Chronic
ACUTE SYMPTOMS
 minutes of exposure
 dystonia
 generalized in children and focal in
adults (blepharospasm, torticollis,
oromandibular dystonia)
 IV benzodiazpine (diazepam 10-20
mg, lorazepam 2-4 mg)
 Dopamine agonist
SUBACUTE SYMPTOMS
 Akathisia
 motor restlessness with a need to
move that is alleviated by movement
 removing the offending agent
 benzodiazepine, anticholinergics,
beta blockers or dopamine agonists.
CHRONIC SYMPTOMS
 Tardive dyskinesia
 Tardative dystonia: axial muscles, trunk,
pelvis
 Tardive akathisia
 Tardive Tourette's
 Tardive tremor syndrome
 Neuroepileptic Malignant Syndrome
TARDATIVE SYNDROMES
 Tardive dyskinesia (TD)
 choreiform movements in mouth, lips,
tongue, trunk, limbs, respiratory muscles
may also be affected
 remits within 3 months of stopping the
drug, and most patients gradually
improve over the course of several years
 abnormal movements may also develop
or worsen after stopping the offending
agent.
 Atypical antipsychotics: lower risk of TD
TARDATIVE SYNDROMES…
 Younger patients have a lower risk
 Elderly, females, previous organic cerebral
dysfunction at greater risk
 Chronic use with increased risk
(metoclopramide for more than 12 weeks)
 Can be permanent and resistant to
treatment
 atypical neuroleptics should be the
preferred
 Treatment: Stop offending agent
 Patient with traditional antipsychotic 
replace with an atypical antipsychotic
Neuroepileptic Malignant
Syndrome (NMS)
 Acute or subacute onset of:
o muscle rigidity
o elevated temperature
o altered mental status
o tachycardia
o labile blood pressure
o renal failure
o elevated creatine kinase levels
• Evolve within days or weeks after strating
drug
• Abrupt withdrawal of dopaminergic
NMS…
 Stop offending antipsychotic drug
 Introduction of a dopaminergic agent
(dopamine agonist or levodopa),
dantrolene, benzodiazepine.
 Antipyretics, cooling blankets, hydration,
electrolyte replacement, control of renal
function and blood pressure.
MANAGEMENT
 Management of ABC
 Activated charcoal if within 1 hr of
ingestion
 Cardiac monitoring for 6 hrs
 CVS: MgSO4, 2g IV over 1-2 min
 Avoid class IA, IC antiarrhythmics
 NaHCO3
REFERENCES
 Harrison’s Principles of Internal
Medicine, 19th edition
 Davidson’s Principles and practise of
Medicine, 22nd edition
 https://www.ncbi.nlm.nih.gov/pubmed/
22668123
Management of antipsychotic overdose

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Management of antipsychotic overdose

  • 2. ANTIPSYCHOTIC DRUGS  Inhibition of α-adrenergic receptors  Inhibition of dopaminergic receptors  Inhibition of histaminergic receptors  Inhibition of muscarinic receptors  Inhibition of serotonergic receptors  Inhibition sodium, potassium, and calcium channels
  • 3. COMMON USES  Antipsychotic  Control nausea and vomiting  Gastro esophageal disorders
  • 4. SYMPTOMS  Anti-cholinergic features (tachycardia, hypertention, confusion, hallucination, sedation, myoclonus, fever, diplopia, mydriasis, lleus, palpable bladder, flushing, dry mouth  Serotogenic features (tachycardia, <- >BP, confusion, hallucination, sedation, coma, shivering, myoclonus, fever, diarrhea, comitting, flushing)  Prolonged QT interval, torsades de
  • 6. ACUTE SYMPTOMS  minutes of exposure  dystonia  generalized in children and focal in adults (blepharospasm, torticollis, oromandibular dystonia)  IV benzodiazpine (diazepam 10-20 mg, lorazepam 2-4 mg)  Dopamine agonist
  • 7. SUBACUTE SYMPTOMS  Akathisia  motor restlessness with a need to move that is alleviated by movement  removing the offending agent  benzodiazepine, anticholinergics, beta blockers or dopamine agonists.
  • 8. CHRONIC SYMPTOMS  Tardive dyskinesia  Tardative dystonia: axial muscles, trunk, pelvis  Tardive akathisia  Tardive Tourette's  Tardive tremor syndrome  Neuroepileptic Malignant Syndrome
  • 9. TARDATIVE SYNDROMES  Tardive dyskinesia (TD)  choreiform movements in mouth, lips, tongue, trunk, limbs, respiratory muscles may also be affected  remits within 3 months of stopping the drug, and most patients gradually improve over the course of several years  abnormal movements may also develop or worsen after stopping the offending agent.  Atypical antipsychotics: lower risk of TD
  • 10. TARDATIVE SYNDROMES…  Younger patients have a lower risk  Elderly, females, previous organic cerebral dysfunction at greater risk  Chronic use with increased risk (metoclopramide for more than 12 weeks)  Can be permanent and resistant to treatment  atypical neuroleptics should be the preferred  Treatment: Stop offending agent  Patient with traditional antipsychotic  replace with an atypical antipsychotic
  • 11. Neuroepileptic Malignant Syndrome (NMS)  Acute or subacute onset of: o muscle rigidity o elevated temperature o altered mental status o tachycardia o labile blood pressure o renal failure o elevated creatine kinase levels • Evolve within days or weeks after strating drug • Abrupt withdrawal of dopaminergic
  • 12. NMS…  Stop offending antipsychotic drug  Introduction of a dopaminergic agent (dopamine agonist or levodopa), dantrolene, benzodiazepine.  Antipyretics, cooling blankets, hydration, electrolyte replacement, control of renal function and blood pressure.
  • 13. MANAGEMENT  Management of ABC  Activated charcoal if within 1 hr of ingestion  Cardiac monitoring for 6 hrs  CVS: MgSO4, 2g IV over 1-2 min  Avoid class IA, IC antiarrhythmics  NaHCO3
  • 14. REFERENCES  Harrison’s Principles of Internal Medicine, 19th edition  Davidson’s Principles and practise of Medicine, 22nd edition  https://www.ncbi.nlm.nih.gov/pubmed/ 22668123

Editor's Notes

  1. Torsades de pointes is a specific form of polymorphic VT in patients with a long QT interval. It is characterized by rapid, irregular QRS complexes, which appear to be twisting around the ECG baseline. This arrhythmia may cease spontaneously or degenerate into ventricular fibrillation. The extrapyramidal symptoms include acute dyskinesiasand dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome.
  2. pramipexole and ropinirole
  3. Akathisia is a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting.
  4.  repetitive and rapid, jerky, involuntary movement that appears to be well-coordinated Atypical antipsychotics (e.g目, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole)
  5. withdrawal)Benefits may occasionally be achieved with valproic acid,anticholinergics, or botulinum toxin injections. In refractory cases, catecholamine depleters such as tetrabenazine may be helpful, but this drug can be associated with dose-dependent