A 55-year-old woman is admitted to the hospital for vomiting resulting in hypokalemia and acute kidney injury. She has had nausea and vomiting after meals for the last several months; these have become progressively more severe. The symptoms are associated with dull abdominal pain and improve with fasting. Five years ago, the patient was diagnosed with type 2 diabetes mellitus for which she takes insulin. However, she reports often missing doses. Her most recent hemoglobin A1c is 10.1%. The patient has no known allergies. She does not use tobacco, alcohol, or recreational drugs. She is given intravenous hydration with electrolyte repletion, and her symptoms are improved with metoclopramide and ondansetron. In the evening, she calls urgently to the nurse for help. The patient reports sudden inability to move her neck to the left and says there were no preceding symptoms such as numbness, tingling, weakness, or anxiety. Temperature is 36.5 C (97.7 C), pulse is 115/min, blood pressure is 160/100 mm Hg, and respirations are 25/min. The patient is in distress but is able to speak with a normal voice. Auscultation reveals normal S1 and S2 and a regular, fast rhythm. Her neck is in a flexed position and rotated toward the right. The muscles of the neck are tense, but the remainder of the examination is normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 55-year-old woman is admitted to the hospital for vomiting resulting in hypokalemia and acute kidney injury.  She has had nausea and vomiting after meals for the last several months; these have become progressively more severe.  The symptoms are associated with dull abdominal pain and improve with fasting.  Five years ago, the patient was diagnosed with type 2 diabetes mellitus for which she takes insulin.  However, she reports often missing doses.  Her most recent hemoglobin A1c is 10.1%.  The patient has no known allergies.  She does not use tobacco, alcohol, or recreational drugs.  She is given intravenous hydration with electrolyte repletion, and her symptoms are improved with metoclopramide and ondansetron.  In the evening, she calls urgently to the nurse for help.  The patient reports sudden inability to move her neck to the left and says there were no preceding symptoms such as numbness, tingling, weakness, or anxiety.  Temperature is 36.5 C (97.7 C), pulse is 115/min, blood pressure is 160/100 mm Hg, and respirations are 25/min.  The patient is in distress but is able to speak with a normal voice.  Auscultation reveals normal S1 and S2 and a regular, fast rhythm.  Her neck is in a flexed position and rotated toward the right.  The muscles of the neck are tense, but the remainder of the examination is normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient with uncontrolled diabetes and likely diabetic gastroparesis (nausea, vomiting, and abdominal pain following meals) is experiencing an acute dystonic reaction known as torticollis (involuntary contraction of the neck musculature) related to metoclopramide use. Metoclopramide is a dopamine receptor antagonist and serotonin receptor agonist that promotes gastric emptying and improves nausea and vomiting. Any dopamine receptor antagonist that crosses the blood brain barrier, including metoclopramide and multiple antipsychotics, can cause extrapyramidal effects that include dystonia, akathisia (restlessness), and parkinsonism. Extrapyramidal symptoms are uncommon with low doses of metoclopramide, but their incidence may exceed 30% with high doses. These symptoms usually occur within 24-48 hours after initiation of therapy. Diphenhydramine or benztropine are the drugs of choice for the immediate treatment of metoclopramide-induced acute dystonia due to their anticholinergic effects. Intravenous forms of these medications typically provide quick relief of symptoms (within 3-5 minutes). (Choice A) Calcium chloride is used to replete serum calcium. Hypocalcemia can cause muscle spasms due to tetany; however, symptoms are typically more diffuse and associated with perioral paresthesias. In addition, nausea and vomiting do not typically lead to hypocalcemia. (Choice B) Dantrolene is a peripheral muscle relaxant often used in the treatment of neuroleptic malignant syndrome, although its benefit is unclear. Neuroleptic malignant syndrome is thought to be associated with dopamine antagonists and causes altered mental status, fevers, and rigidity. This patient has an isolated muscle group contraction and does not have a fever or mental status change. (Choice D) Intravenous magnesium is used to treat torsades de pointes. This patient is only mildly tachycardic and has a regular rhythm, likely an anxiety-induced sinus tachycardia due to distressing symptoms. (Choice E) Hypertension noted in this patient is likely due to distress from the development of dystonia. Initial management would be treatment of the dystonia, which may result in decreased blood pressure. Educational objective: Anticholinergic medications such as intravenous diphenhydramine or benztropine are the drugs of choice for immediate treatment of metoclopramide-induced acute dystonia.

A 55-Year-Old Woman Is Admitted to the Hospital for Vomiting