Neuroleptic Malignant Syndrome in Emergency Medicine Follow-up

  • Author: Theodore I Benzer, MD, PhD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Sep 1, 2010
 

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.
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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.

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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.

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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.

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Complications

Complications of neuroleptic malignant syndrome may include the following:

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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).
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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.

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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.

Specialty Editor Board

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.

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.

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.

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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