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Neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is a life-threatening, neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs. It is considered to be a very serious neurological disorder. more...

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NMS is caused almost exclusively by antipsychotics, which includes all types of neuroleptic medicines along with newer antipsychotic drugs. The higher the dosage, the more common the occurrence. Rapid and large increases in dosage can also be attributed to the development of NMS. Other drugs, environmental or psychological factors, hereditary conditions, and specific demographics may be at greater risk, but to date no conclusive evidence has been found to support this. The disorder typically develops within two weeks of the initial treatment with the drug, but may develop at any time that the drug is being taken. NMS may also occur in people taking a class of drugs known as dopaminergics.


The first symptom to develop is usually muscular rigidity, followed by high fever and changes in cognitive functions. Other symptoms can vary, but may be unstable blood pressure, confusion, coma, delirium, muscle tremors, etc. Once symptoms do appear, they rapidly progress and can reach peak intensity in no more than three days. These symptoms can last as little as eight hours or as long as forty days.


As with most illnesses, the prognosis is best when identified early and treated aggressively. In these cases, NMS is usually not fatal, although there is currently no agreement on the exact mortality rate for the disorder. Studies have given the disorder a mortality rate as low as 5% and as high as 76%, although most studies agree that the correct percentage is in the lower spectrum, perhaps between 10% - 20%. Re-introduction to the drug that originally caused NMS to develop may also trigger a recurrence, although in most cases it does not.


Although treatment is not always necessary, it will help to cure the disease and prevent fatal developments from occurring. The first step in treatment is generally to remove the patient from any neuroleptic or antipsychotic drugs being taken and to treat fever agressively. Many cases require intensive care, or some kind of supportive care at the minimum. Depending on the severity of the case, patients may require other treatments to contend with specific effects of the disorder. These include circulator and ventilatory support, the drugs dantrolene sodium, bromocriptine, apomorphine and electroconvulsive therapy (ECT) if medication fails.


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Neuroleptic malignant syndrome
From Nursing, 1/1/01 by Rother, Lorraine Flint

FEARFUL AND AGITATED, Theresa Gordon, 21, is in your psychiatric unit for treatment of acute psychosis. An hour ago, she was given 5 mg of haloperidol intramuscularly (LM.). Now she's sweating profusely, speaking incoherently, and is disoriented. Her arms and legs are stiff. You take her vital signs: temperature, 1010 F (38.30 C); BP, 130/100; pulse, 110; and respirations, 22.

What's the situation?

For the past few days, Ms. Gordon has been increasingly agitated, although she had no fever and was otherwise in good health. Her family says that for most of the day before her hospital admission, she was pacing and hadn't taken any food or fluid.

This is Ms. Gordon's second psychotic episode; during the first, about a year ago, she was treated with a single LM. injection of 2.5 mg of haloperidol. Her family tells you that Ms. Gordon had a severe stiff neck after the injection, which was successfully treated with benztropine. The psychotic episode resolved and she required no further treatment.

What's your assessment?

Ms. Gordon's history and signs and symptoms-particularly the unstable vital signs, diaphoresis, mental confusion, muscle rigidity, and unstable vital signs-- lead you to suspect neuroleptic malignant syndrome (NMS), a rare but potentially fatal adverse reaction to antipsychotic medications that leads to autonomic dysfunction. Other signs and symptoms of NMS include incontinence, tremor, and increased salivation.

Neuroleptic malignant syndrome is more common in men than women, but Ms. Gordon has several risk factors, including a history of extrapyramidal reactions to antipsychotic medications, physical exhaustion, and possible dehydration.

What must you do immediately?

Page the house physician and hold all antipsychotic medications. Notify Ms. Gordon's psychiatrist. Provide one-to-one observation and explain to Ms. Gordon that she's having a reaction to her medications.

Closely monitor Ms. Gordon's vital signs and establish intravenous access for fluid administration--or give oral fluids and immediately transfer her to a medical unit or intensive care unit (ICU)because dehydration can exacerbate her condition. Because hyperthermia predisposes Ms. Gordon to seizures, administer an antipyretic as prescribed, give her a tepid sponge bath and, if needed, place her on a temperatureregulating blanket if one is available in your unit.

As ordered, obtain samples for a complete blood cell count, liver function tests, serum electrolytes, arterial blood gas analysis, creatine phosphokinase (CPK), urinalysis, and urine myoglobin. These tests show elevated CPK, white blood cells, and liver function tests, indicating NMS, and myoglobinuria and proteinuria, indicating muscle deterioration and early-stage renal insufficiency.

As prescribed, administer a dopaminergic agent, such as bromocriptine (Parlodel) or amantadine (Symmetrel), to increase dopamine levels and reverse the autonomic dysfunction. To stop muscle catabolism and reduce the risk of renal failure from rhabdomyolysis, administer dantrolene as prescribed. The physician also may order a sedative such as lorazepam.

Reorient Ms. Gordon as needed. Have the same staff member sit with her, if possible, and try to keep the environment quiet.

What should be done later?

Ms. Gordon will be transferred to the ICU. Her psychiatric status will be closely watched as she recovers. When all symptoms of NMS abate, certain antipsychotic drugs may be reintroduced very cautiously. Ms. Gordon's health care providers need to be told about her reaction because although NMS is more common with potent antipsychotics such as haloperidol and fluphenazine, it can be caused by any antipsychotic medication, even the new atypical antipsychotics. Place an allergy alert in Ms. Gordon's medical record and thoroughly document the incident in your notes.

Copyright Springhouse Corporation Jan 2001
Provided by ProQuest Information and Learning Company. All rights Reserved

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