A 25-year-old homeless man with a history of schizophrenia is brought to the hospital by local police. He destroyed a television set at a local electronics store and then became extremely agitated and violent when employees attempted to intervene. The patient's speech is difficult to follow, and he is distracted, seemingly listening to voices that only he can hear. He is admitted to the psychiatric ward and given haloperidol, which calms him down. Later that evening, however, he walks to the nurses' station and says, "What's happening to me?" The patient is upset and refuses to sit down, pointing to his neck. Physical examination shows a sustained contraction of his neck to the right side. Which of the following is the most appropriate next step in management?

Question

A 25-year-old homeless man with a history of schizophrenia is brought to the hospital by local police.  He destroyed a television set at a local electronics store and then became extremely agitated and violent when employees attempted to intervene.  The patient's speech is difficult to follow, and he is distracted, seemingly listening to voices that only he can hear.  He is admitted to the psychiatric ward and given haloperidol, which calms him down.  Later that evening, however, he walks to the nurses' station and says, "What's happening to me?"  The patient is upset and refuses to sit down, pointing to his neck.  Physical examination shows a sustained contraction of his neck to the right side.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d794_2585_bc81_89c2df67eb01_MD0003_00 This patient is experiencing an acute dystonic reaction due to haloperidol, a high-potency first-generation antipsychotic (FGA). Acute dystonia is a type of extrapyramidal symptom (EPS) that develops within hours to days of initiation or dose escalation of an antipsychotic. It is characterized by muscle spasms or stiffness in the head and neck, including tongue protrusions or twisting, facial grimacing, torticollis, opisthotonos (back), and oculogyric crisis (forced, sustained elevation of the eyes in an upward position). The risk of acute dystonia is greater with high-potency FGAs (eg, haloperidol) compared to low-potency FGAs and second-generation antipsychotics (SGAs). Acute dystonia should be distinguished from 2 other types of EPS: akathisia (inner restlessness) and drug-induced parkinsonism (tremor, rigidity, bradykinesia, masked facies). Acute dystonic reactions are treated with anticholinergic medications (benztropine) and antihistamines (diphenhydramine) that have significant anticholinergic activity. Other subsequent management strategies for EPS include antipsychotic dose reduction if feasible or switching to an SGA with a lower risk of extrapyramidal effects. (Choice A) Amantadine is a dopaminergic medication with weak antagonism of the N-methyl-D-aspartate glutamate receptor; it is 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 high fever, muscle rigidity, and rhabdomyolysis. (Choice D) Levodopa is a treatment for Parkinson disease. When parkinsonism develops as a side effect of antipsychotic use, the preferred treatment is benztropine or amantadine. (Choices E and F) Although it is possible that this patient's refusal to sit down is related to akathisia (restlessness and inability to sit still), he is more likely distressed by his acute dystonic reaction. Even if akathisia were present, treatment of acute dystonia would take precedence. Akathisia may be treated with beta blockers (eg, propranolol) and benzodiazepines (eg, lorazepam). (Choice G) Quetiapine is an SGA with a low risk of causing extrapyramidal side effects. Switching the patient from a high-potency FGA to an SGA would be an effective long-term strategy to decrease the risk of recurrence of acute dystonia but would not relieve his acute symptoms. (Choice H) Valbenazine is a vesicular monoamine transporter 2 inhibitor used for the treatment of tardive dyskinesia. Educational objective: Acute dystonia is a type of extrapyramidal symptom associated with antipsychotic treatment. It is most commonly seen with high-potency first-generation antipsychotics and is best 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) Medication-induced acute dystonic reaction: the challenge of diagnosing movement disorders in the intensive care unit. (http://www.ncbi.nlm.nih.gov/pubmed/26392457)

A 25-Year-Old Homeless Man with a History of Schizophrenia Is