eMedicine Specialties > Emergency Medicine > Toxicology

Neuroleptic Malignant Syndrome: Follow-up

Author: Theodore I Benzer, MD, PhD, Assistant Professor in Medicine, Harvard Medical School; Director of Clinical Operations, Director of Toxicology, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Aug 18, 2009

Follow-up

Further Inpatient Care

  • Additional evaluation and treatment should be in an inpatient setting, preferably an ICU.
  • The patient must be monitored closely to rule out underlying infection.
  • Adequate hydration must be maintained.
  • Rhabdomyolysis must be diagnosed and treated aggressively with alkalinization and hydration to prevent renal failure.
  • The patient's psychiatric disease must be evaluated and treated during withdrawal of the neuroleptic medication.
    • Challenge with an atypical antipsychotic may be appropriate since these drugs have a lower incidence of neuroleptic malignant syndrome (NMS).
    • Treatment with ECT may be useful to treat the underlying psychiatric disease after an episode of NMS.

Further Outpatient Care

  • NMS may be prolonged. If the patient is discharged, close follow-up care should be given to monitor residual symptoms. If neuroleptics are to be reinstituted, they should be administered at relatively low initial doses.

Transfer

  • If NMS is diagnosed in a psychiatric facility, the patient should be transferred to an acute care medical facility where intensive monitoring and treatment is available.

Deterrence/Prevention

  • Take a careful history before starting a new neuroleptic medication. NMS frequently recurs when medications are restarted.
  • Monitor a patient carefully while administering neuroleptic medication to prevent excessive agitation and dehydration because these conditions may predispose a patient to NMS.
  • Benzodiazepines and physical restraints may be useful.

Complications

Prognosis

  • Increased mortality, up to 50%, is seen in patients who develop renal failure during an episode of NMS.
  • In the absence of rhabdomyolysis, renal failure, or aspiration pneumonia, and with good supportive care, the prognosis for recovery is good.
  • The syndrome may last 7-10 days after discontinuing oral neuroleptics and up to 21 days after using depot neuroleptics (eg, fluphenazine).

Patient Education

  • After an episode of NMS, the patient must be told that he or she is at risk for recurrence if rechallenged with a neuroleptic medication. The patient should report this reaction to all health care providers.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider this diagnosis and to institute prompt therapies
  • Failure to consider other non-NMS diagnoses as the cause of similar symptoms
  • Failure to obtain a prior history of NMS before instituting medical therapies with any medications known to cause NMS
 


More on Neuroleptic Malignant Syndrome

Overview: Neuroleptic Malignant Syndrome
Differential Diagnoses & Workup: Neuroleptic Malignant Syndrome
Treatment & Medication: Neuroleptic Malignant Syndrome
Follow-up: Neuroleptic Malignant Syndrome
References
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Further Reading

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Keywords

neuroleptic malignant syndrome, neuroleptic medication, NMS, idiosyncratic reaction, muscular rigidity, autonomic dysfunction, haloperidol, fluphenazine, antipsychotic agents, prochlorperazine, promethazine, clozapine, risperidone, metoclopramide, amoxapine, lithium, dopamine D2-receptor antagonist, withdrawal of anti-Parkinson medication, respiratory failure, cardiovascular collapse, myoglobinuric renal failure, arrhythmias, diffuse intravascular coagulation, DIC, rhabdomyolysis, pneumonia, renal failure, seizures, hyperthermia, profuse diaphoresis, sialorrhea, metabolic acidosis, dopamine receptor blockade, impaired temperature regulation

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Contributor Information and Disclosures

Author

Theodore I Benzer, MD, PhD, Assistant Professor in Medicine, Harvard Medical School; Director of Clinical Operations, Director of Toxicology, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital
Theodore I Benzer, MD, PhD is a member of the following medical societies: Alpha Omega Alpha and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Mark S Slabinski, MD, FACEP, FAAEM, Vice President, EMP Medical Group
Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & 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.

Managing Editor

Michael J Burns, MD, Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center
Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

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, Department of Surgery, Section 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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