Neuroleptic Agent Toxicity Follow-up

  • Author: Kathryn Ruth Challoner, MD, MPH, FACEP; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Jun 23, 2010
 

Further Inpatient Care

  • Patients who develop signs of potentially serious toxicity require admission.
  • Patients who remain asymptomatic after a period of observation (6 h recommended) can be discharged home or given psychiatric evaluation.
  • Potentially serious signs of toxicity include persistent hypotension, dysrhythmias or abnormal ECG, seizures, or movement disorders that fail to respond to anticholinergic treatment.
  • Patients with dysrhythmias, status epilepticus, coma, or those who require pressor agents to maintain blood pressure should be treated in an ICU setting.
  • Repeated doses of activated charcoal every 6 hours without cathartics may increase clearance of some neuroleptics that undergo enterohepatic circulation. There must be no ileus of the gut for this method of enhanced elimination. Perform standard measures for treating comatose patients (eg, eye care, position changes).
  • Once the patient is stable and awake, psychiatric evaluation can take place before discharge from hospital.
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Further Outpatient Care

Follow-up with a psychiatrist is recommended for patients with intentional overdose and for those who require medication changes because of adverse effects from neuroleptics.

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Inpatient & Outpatient Medications

Most patients with neuroleptic overdose recover without sequelae and do not require ongoing medical treatment.

  • Patients who have developed NMS pose a difficult problem if they require ongoing antipsychotic medication monitoring and adjustment.
  • Neuroleptics have been successfully reintroduced following episodes of NMS, but this must be done carefully and under the supervision of a psychiatrist.
  • Alternative medications with a lower potency that are less likely to produce NMS may be used.
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Transfer

  • Patients with an acute overdose of neuroleptic medication can be transferred if they are stable for a period of 6 hours. Transferring a patient before 6 hours of observation is imprudent because risk of developing seizures, hypotension, and dysrhythmias is present.
  • Patients with NMS are critically ill and generally are not candidates for transfer, unless the initial treating facility is unable to provide adequate medical care. Once the patient appears to be improving and is clinically stable with decreasing CK levels and normal mentation, transfer may be undertaken safely.
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Complications

  • The vast majority of patients with acute neuroleptic overdose recover completely. However, prolonged periods of hypoxia, hyperthermia, status epilepticus, or hypotension may result in permanent neurologic or cardiac disability.
  • TD is the most frequently noted permanent disability related to prolonged use of neuroleptics.
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Prognosis

  • The outcome from an acute overdose of neuroleptic medication is usually favorable.
  • Permanent deficits occur in very few cases.
  • Poor outcomes are most often associated with small children, patients who develop NMS, and those who sustain dysrhythmias or prolonged hypotension.
  • TD is usually permanent.
  • Parkinsonism, akathisia, and dystonias remit on discontinuation of the drug.
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Patient Education

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Contributor Information and Disclosures
Author

Kathryn Ruth Challoner, MD, MPH, FACEP  Clinical Professor of Emergency Medicine, Department of Emergency Medicine, Keck School of Medicine of the University of Southern California

Kathryn Ruth Challoner, MD, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Edward J Newton, MD, FACEP, FRCPC  Professor of Clinical Emergency Medicine, Chairman, Department of Emergency Medicine, University of Southern California Keck School of Medicine

Edward J Newton, MD, FACEP, FRCPC is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Royal College of Physicians and Surgeons of Canada, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Peter MC DeBlieux, MD  Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University School of Medicine in New Orleans

Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP  Director of Medical Toxicology, Allegheny General Hospital

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

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