A 23-year-old man newly diagnosed with bipolar disorder was admitted to the psychiatry unit 3 days ago. Since admission, he has spent all of his time at the nurses' station trying to convince the staff to discharge him. His speech is very loud and difficult to interrupt. He states that his roommate is "hitting" on him because of his good looks, and refuses to eat the food because it is not up to his standards. In addition, he is worried that he will miss his meeting with the President, which he says may cause the country to be forced into war. Despite attempts to redirect the patient, he becomes progressively more agitated and starts to verbally threaten the staff. He bangs on the desk at the nurses' station and throws a chair down the hallway. The patient is given emergency intramuscular haloperidol to decrease his agitation. A few hours later, the patient approaches the nurses' station screaming, "Something is wrong. Look what you did to me! I have been poisoned! Get me out of here immediately before I die!" Examination shows sustained upward deviation of the eyes and tilting of the neck to the right side. Which of the following is the most appropriate course of action?

Question

A 23-year-old man newly diagnosed with bipolar disorder was admitted to the psychiatry unit 3 days ago.  Since admission, he has spent all of his time at the nurses' station trying to convince the staff to discharge him.  His speech is very loud and difficult to interrupt.  He states that his roommate is "hitting" on him because of his good looks, and refuses to eat the food because it is not up to his standards.  In addition, he is worried that he will miss his meeting with the President, which he says may cause the country to be forced into war.  Despite attempts to redirect the patient, he becomes progressively more agitated and starts to verbally threaten the staff.  He bangs on the desk at the nurses' station and throws a chair down the hallway.  The patient is given emergency intramuscular haloperidol to decrease his agitation.  A few hours later, the patient approaches the nurses' station screaming, "Something is wrong.  Look what you did to me!  I have been poisoned!  Get me out of here immediately before I die!"  Examination shows sustained upward deviation of the eyes and tilting of the neck to the right side.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c052_9232_8f63_473ad2c9fdab_MD0005_00 This patient is experiencing an acute dystonic reaction manifested by torticollis and an oculogyric crisis (forced, sustained elevation of the eyes in an upward position). Acute dystonia is a type of extrapyramidal symptom (EPS) that develops within hours to days of starting or dose escalation of antipsychotics. This patient's risk factors include young age, male sex, and use of a high-potency, first-generation antipsychotic (haloperidol). Other types of EPS include akathisia (inner restlessness) and drug-induced parkinsonism (tremor, rigidity, bradykinesia, masked facies). Very distressing acute dystonic reactions are best treated with anticholinergic medication administered intravenously or intramuscularly. Diphenhydramine, an antihistamine with significant anticholinergic activity, or benztropine is commonly used. (Choice A) Amantadine is a dopamine agonist used to treat drug-induced parkinsonism, not acute dystonic reactions. (Choice B) Dantrolene is a muscle relaxant that has been used in severe cases of neuroleptic malignant syndrome, a rare but life-threatening condition characterized by mental status change, high fever, autonomic instability, and diffuse muscle rigidity. (Choice D) Lorazepam may be given to help reduce anxiety but will not relieve acute dystonia. Lorazepam is sometimes used to treat akathisia, another type of EPS. (Choice E) Although acute dystonic reactions can resolve spontaneously with discontinuation of the offending medication, they are usually very distressing and uncomfortable for the patient. Therefore, this patient should be treated with diphenhydramine. Educational objective: Acute dystonic reaction is a type of extrapyramidal symptom that is highly disturbing to patients. It is most commonly seen with high-potency, first-generation antipsychotics and is treated with anticholinergics (benztropine) or antihistamines (diphenhydramine). References: Acute dystonic reaction as medical emergency: a report of two cases. (http://www.ncbi.nlm.nih.gov/pubmed/24116333)

A 23-Year-Old Man Newly Diagnosed with Bipolar Disorder Was Admitted