Neuroleptic Malignant Syndrome in Emergency Medicine Treatment & Management

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

Prehospital Care

Any patient being evaluated by prehospital personnel requires assessment of the airway, breathing, and circulation (ABCs).

Any patient with altered mental status should receive thiamine, dextrose (or rapid glucose determination), and naloxone.

Prehospital personnel must assess the patient's safety and, if necessary, restrain the patient. Restraint use in agitated, hyperthermic patients can increase the risk of significant morbidity and mortality in various disease states (eg, NMS, cocaine intoxication, amphetamine abuse). Chemical restraints (eg, benzodiazepines), if available, may be preferable in such situations.

Prehospital personnel should try to get an accurate medication list. If that is impossible, bring all the medication bottles found with the patient. Simultaneous administration of 2 dopamine-blocking agents can sometimes precipitate NMS.

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Emergency Department Care

Successful treatment requires prompt recognition, withdrawal of neuroleptic agent, exclusion of other medical conditions, aggressive supportive care, and administration of certain pharmacotherapies.

  • A careful history should be taken before starting a new neuroleptic medication.
  • NMS may recur 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.
  • Stop all neuroleptics.
  • Correct volume depletion and hypotension with intravenous fluids.
  • Methods to reduce the temperature include the following:
    • Cooling blankets
    • Antipyretics
    • Cooled intravenous fluids
    • Ice packs
    • Evaporative cooling
    • Various pharmacotherapies to reduce rigidity (see below)
  • When rhabdomyolysis occurs, maintain vigorous hydration and alkalinize the urine with intravenous NaHCO3 to prevent renal failure.
  • Electroconvulsive therapy (ECT) has been used to treat NMS. It can help with the alteration of temperature, level of consciousness, and diaphoresis. It may also be useful in treating the underlying psychiatric disease in patients who are unable to take neuroleptics. ECT with anesthesia has generally been safe with no increased incidence of malignant hyperthermia from succinylcholine administration.[5, 6]
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Consultations

  • Consultation with a neurologist may be needed if the diagnosis is in question.
  • Consultation with a psychiatrist can be helpful to manage the underlying psychiatric disease once the neuroleptics have been withdrawn.
  • Consultation with a nephrologist is needed if the patient develops rhabdomyolysis and renal failure.
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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.

References

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  2. Gurrera RJ. Sympathoadrenal hyperactivity and the etiology of neuroleptic malignant syndrome. Am J Psychiatry. Feb 1999;156(2):169-80. [Medline].

  3. Jauss M, Krack P, Franz M, Klett R, Bauer R, Gallhofer B, et al. Imaging of dopamine receptors with [123I]iodobenzamide single-photon emission-computed tomography in neuroleptic malignant syndrome. Mov Disord. Nov 1996;11(6):726-8. [Medline].

  4. Picard LS, Lindsay S, Strawn JR, Kaneria RM, Patel NC, Keck PE Jr. Atypical neuroleptic malignant syndrome: diagnostic controversies and considerations. Pharmacotherapy. Apr 2008;28(4):530-5. [Medline].

  5. Ozer F, Meral H, Aydin B, Hanoglu L, Aydemir T, Oral T. Electroconvulsive therapy in drug-induced psychiatric states and neuroleptic malignant syndrome. J ECT. Jun 2005;21(2):125-7. [Medline].

  6. Hermesh H, Aizenberg D, Weizman A. A successful electroconvulsive treatment of neuroleptic malignant syndrome. Acta Psychiatr Scand. Mar 1987;75(3):237-9. [Medline].

  7. Rosebush PI, Stewart T, Mazurek MF. The treatment of neuroleptic malignant syndrome. Are dantrolene and bromocriptine useful adjuncts to supportive care?. Br J Psychiatry. Nov 1991;159:709-12. [Medline].

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  19. Nierenberg D, Disch M, Manheimer E, Patterson J, Ross J, Silvestri G, et al. Facilitating prompt diagnosis and treatment of the neuroleptic malignant syndrome. Clin Pharmacol Ther. Nov 1991;50(5 Pt 1):580-6. [Medline].

  20. Reulbach U, Dütsch C, Biermann T, Sperling W, Thuerauf N, Kornhuber J, et al. Managing an effective treatment for neuroleptic malignant syndrome. Crit Care. 2007;11(1):R4. [Medline].

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