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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.
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
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.
pramipexole and ropinirole
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.
repetitive and rapid, jerky, involuntary movement that appears to be well-coordinated
Atypical antipsychotics (e.g目, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole)
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