A 26-year-old man is brought to the emergency department by police after he was found disoriented and wandering on the street. No medical history is available. The patient is agitated and violent but calms down after several doses of lorazepam and haloperidol. Physical examination reveals confusion and bilateral horizontal nystagmus but no other focal neurologic findings. There are abrasions on the lower extremities. Urine drug screen is positive for phencyclidine. The patient is hospitalized for observation. Several hours later, his agitation and confusion have improved, but he reports difficulty with his vision. Temperature is 37.1 C (98.8 F), blood pressure is 134/84 mm Hg, pulse is 88/min, and respirations are 16/min. On examination, both eyes are deviated superiorly, and extraocular movement is restricted. There is rigidity of the neck and upper extremities. Noncontrast CT scan of the head shows no intracranial hemorrhage. Which of the following is most appropriate pharmacotherapy for this patient's current condition?

Question

A 26-year-old man is brought to the emergency department by police after he was found disoriented and wandering on the street.  No medical history is available.  The patient is agitated and violent but calms down after several doses of lorazepam and haloperidol.  Physical examination reveals confusion and bilateral horizontal nystagmus but no other focal neurologic findings.  There are abrasions on the lower extremities.  Urine drug screen is positive for phencyclidine.  The patient is hospitalized for observation.  Several hours later, his agitation and confusion have improved, but he reports difficulty with his vision.  Temperature is 37.1 C (98.8 F), blood pressure is 134/84 mm Hg, pulse is 88/min, and respirations are 16/min.  On examination, both eyes are deviated superiorly, and extraocular movement is restricted.  There is rigidity of the neck and upper extremities.  Noncontrast CT scan of the head shows no intracranial hemorrhage.  Which of the following is most appropriate pharmacotherapy for this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d758_caf9_bc81_91b38ab03437_MD0003_00 This patient has abrupt-onset upper extremity and neck rigidity associated with upward gaze deviation and restricted extraocular movement after receiving multiple doses of haloperidol. This presentation suggests an acute dystonic reaction. Acute dystonia (involuntary muscle contraction) typically occurs as an extrapyramidal symptom of antipsychotic medications or metoclopramide. These drugs antagonize dopamine receptors and lead to an imbalance between dopamine and acetylcholine in the basal ganglia. High-potency first-generation antipsychotics (eg, haloperidol, fluphenazine) are particularly high risk. Other risk factors include young age, high muscle mass, male sex, recent cocaine use, and prior dystonic reactions. Dystonias may be focal or diffuse; however, they often involve the small muscles of the head and neck. Oculogyric crisis, as seen in this patient, results in a forced upward gaze deviation; other common dystonias include torticollis, blepharospasm, and trismus. Management includes intravenous anticholinergic medications (eg, benztropine, trihexyphenidyl), often given in association with an antihistamine (eg, diphenhydramine). Further management includes stoppage or dose reduction of the offending medication. (Choice A) Acyclovir is used to treat herpes meningitis or encephalitis, which could cause neck stiffness (ie, meningismus) but would not be expected to cause oculogyric crisis. In addition, patients typically have headache and photophobia, and oral or genital lesions are often present. (Choice C) Dantrolene is used in the treatment of neuroleptic malignant syndrome, which can occur with high-potency first-generation antipsychotics. However, this syndrome is characterized by hyperthermia, tachycardia, hypertension, and altered mental status. Although muscular rigidity is common, it is typically diffuse and more severe (lead-pipe rigidity). (Choice D) Fosphenytoin is often administered with lorazepam for status epilepticus. Although seizures can cause gaze deviation and muscle rigidity, most patients are unresponsive or altered during these periods. After administration of multiple doses of haloperidol, acute dystonia is much more likely. (Choice E) Tetanus intravenous immunoglobulin is used to treat tetanus, which can cause generalized or localized muscle spasm; however, these spasms are typically intermittent and often characterized by risus sardonicus (ie, sardonic smile), opisthotonos (ie, rigidly arched back and neck), and dysphagia. Tetanus does not typically cause eye deviation. Educational objective: Dystonias are involuntary muscle contractions that often involve the small muscles of the head and neck; oculogyric crisis results in a forced upward gaze deviation. Dystonias typically occur as extrapyramidal symptoms of a high-potency, first-generation antipsychotic (eg, haloperidol, fluphenazine). Management includes benztropine and diphenhydramine.

A 26-Year-Old Man Is Brought to the Emergency Department by Police