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Neuroleptic Malignant Syndrome, Electroconvulsive Therapy and Other Treatments

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Neuroleptic Malignant Syndrome, Electroconvulsive Therapy and Other Treatments NEUROLEPTIC MALIGNANT SYNDROME, ELECTROCONVULSIVE THERAPY AND OTHER TREATMENTS JASSIN M. JOURIA, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. Abstract Neuroleptic Malignant Syndrome is both rare and potentially fatal. Health clinicians need to recognize signs and symptoms and ask the right questions to make an accurate diagnosis and begin treatment. While this condition is not entirely understood, its symptoms are recognizable and typically easily resolved with little or no long-term impact to the patient when caught early. A treatment and management plan must be implemented. Pharmacotherapy has not been consistently effective in all case reports of neuroleptic malignant syndrome. In contrast, electroconvulsive therapy may be effective. A key step in the management of neuroleptic malignant syndrome is the initiation of supportive medical therapy. 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacy content is 0.5 hour (30 minutes). Statement of Learning Need Because NMS can be a life-threatening condition and is relatively infrequent, it requires timely and accurate diagnosis and treatment. Better recognition and monitoring of its symptoms by clinicians early on in the course of antipsychotic treatment is needed to reduce the number of severe cases of NMS and limit this significant source of morbidity and mortality among patients receiving antipsychotics. Course Purpose To provide clinicians with knowledge of the signs and symptoms of NMS and with 2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com the ability to distinguish NMS from other conditions that have similar signs and symptoms. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. Patients typically develop neuroleptic malignant syndrome a. one month after cessation of a causative drug. b. one month after exposure to a causative drug. c. two weeks after exposure to a causative drug. d. within hours or days after exposure to a causative drug. 2. True or False: Neuroleptic malignant syndrome in hospitalized patients is considered a neurologic emergency as a delay in treatment or withholding of therapeutic measures can potentially lead to serious morbidity or death. a. True b. False 3. Aggressive ______________ is often required, especially if highly elevated creatine phosphokinase (CPK) levels threaten to damage the kidneys. a. electroconvulsive therapy b. hydration c. body cooling d. dose escalation 4. Patients with NMS may be at increased risk of morbidity due to a. renal failure. b. disseminated intravascular coagulation (DIC). c. deep venous thrombosis. d. All of the above 5. Bromocriptine mesylate, a dopamine agonist, a. is used to treat neuroleptic malignant syndrome (NMS). b. is contraindicated in treating NMS. c. is used to treat hypotension. d. may be used to treat NMS but it cannot be administered with dantrolene. 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction It is evident that the clinical presentation of neuroleptic malignant syndrome (NMS) is not homogeneous, but rather, the clinical signs or symptoms are rather heterogeneous, making diagnosis difficult, especially in the early phase. Neuroleptic malignant syndrome usually starts as an unexplainable collection of several symptoms, which include tremor and muscle cramps, unstable blood pressure, and disturbance of mental status, for example, anxiety, agitation, delirium, and fulminant coma (terminal stage). Once NMS has been diagnosed, a plan for treatment and management must be developed. The first step in essentially all cases consists of cessation of the suspected offending neuroleptic pharmacologic agent or reinstituting a dopaminergic medication as quickly as possible if abrupt withdrawal of the medication is the suspected cause of NMS. Neuroleptic malignant syndrome is then managed with supportive medical therapy, and possibly drug treatment. Electroconvulsive therapy (ECT) may be effective when drug treatment or supportive medical therapy fail to provide the desired results. Overview Of NMS And Treatment Options The diagnosis of neuroleptic malignant syndrome (NMS) is based on history and the presence of certain physical examination and laboratory findings. Patients typically develop NMS within hours or days after exposure to a causative drug, with most exhibiting symptoms within 2 weeks and nearly all within 30 days. Although NMS has classically been characterized by the presence of the triad of fever, muscle rigidity, and altered mental status, its presentation can be quite heterogeneous. The clinical course typically begins with muscle rigidity followed by a fever within several hours of onset and mental status changes that can 5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com range from mild drowsiness, agitation, or confusion to a severe delirium or coma.18 Once a diagnosis of NMS has been made there are a number of treatment options. Neuroleptic malignant syndrome in hospitalized patients is considered a neurologic emergency as a delay in treatment or withholding of therapeutic measures can potentially lead to serious morbidity or death. As such, it may be prudent in some cases to treat for NMS even if there is doubt about the diagnosis. Due to its rarity, however, systematic clinical trials in NMS are difficult to perform and so no evidence-based treatment approach exists. Nevertheless, effective general guidelines have been gleaned from case reports and analyses. Successful treatment of NMS depends on early clinical recognition and prompt withdrawal of the neuroleptic agents. Treatment of NMS is individualized and based on the clinical presentation, but the first step in essentially all cases consists of cessation of the suspected offending neuroleptic pharmacologic agent. Neuroleptics cannot be removed by dialysis, and blood concentrations decline only slowly. If the syndrome has occurred due to an abrupt withdrawal of a dopaminergic medication, the medication must be reinstituted as quickly as possible. The next key step in addressing the symptoms of NMS is the initiation of supportive medical therapy. General symptomatic treatment, such as hydration, nutrition and reduction of fever, is essential. Antipsychotic Use And Discontinuance Once a presumptive diagnostic impression is suggested by the clinical history and semiological findings, the single most critical strategy in the therapeutic management of NMS is to discontinue the suspected pharmacological compound. Even while waiting to obtain laboratory results for the CPK or other indices, one should immediately discontinue the potentially harmful compound upon suspicion 6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com of NMS.2 If, however, the syndrome has occurred in the setting of an abrupt withdrawal of a dopaminergic medication, then this medication is reinstituted as quickly as possible. Additional research has supported the medical opinion that all
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