antipsychotic w/drawal: what does it look like?

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MeowMix

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Admitted a medicine pt who showed up with new R-sided weakness and slurred speech. What looked like CVA became complicated by what looks like withdrawal.

I'd appreciate suggestions from anyone who has seen pts like this:
- hyperreflexic, clonus superimposed on her R-sided weakness
- slightly elevated temp, no fevers, flushed, intolerant of heat, hypertensive, like serotonin syndrome
- elevated CK, otherwise completely normal chemistry and CBC, TSH nl
- CT head with 1 cm likely infarct in R basal ganglion, unclear etiology; no MRI 2/2 agitation
- extremely agitated, tolerating relatively high doses of ativan and haldol and versed - what would knock down a normal person does not even touch her

PMH:
- no signif PMH, remote h/o heavy EtOH
- no pain meds, clean urine drug screen
- long h/o mental illness w/ no diagnosis or treatment
- pt has been self-dx and self-medicating with effexor, lamictal, celexa and trazodone at whatever dose she feels necessary - her toolbox is full of literally hundreds of pills bought online

Any experience/suggestions would be helpful and educational.

thanks
 
Admitted a medicine pt who showed up with new R-sided weakness and slurred speech. What looked like CVA became complicated by what looks like withdrawal.

I'd appreciate suggestions from anyone who has seen pts like this:
- hyperreflexic, clonus superimposed on her R-sided weakness
- slightly elevated temp, no fevers, flushed, intolerant of heat, hypertensive, like serotonin syndrome
- elevated CK, otherwise completely normal chemistry and CBC, TSH nl
- CT head with 1 cm likely infarct in R basal ganglion, unclear etiology; no MRI 2/2 agitation
- extremely agitated, tolerating relatively high doses of ativan and haldol and versed - what would knock down a normal person does not even touch her

PMH:
- no signif PMH, remote h/o heavy EtOH
- no pain meds, clean urine drug screen
- long h/o mental illness w/ no diagnosis or treatment
- pt has been self-dx and self-medicating with effexor, lamictal, celexa and trazodone at whatever dose she feels necessary - her toolbox is full of literally hundreds of pills bought online

Any experience/suggestions would be helpful and educational.

thanks

Just go to Up-to-Date NOW and look up "Neuroleptic malignant syndrome".
 
Thanks for the suggestion. I looked into this in my initial reading, and I don't think she is neuroleptic malignant. Temp is near-normal (<100) and no muscle rigidity. Also, these sx are occurring AFTER stopping psych meds that she has been taking for more than 10 years - unless it is the haldol that is causing the problem - hard to tell since she was quite agitated, hyperreflexic, clonus before receiving any haldol. Am I missing something? Any suggestions for handling agitation in this pt without haldol?
 
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Thanks again for the suggestion. I read a bunch more and I still can't reconcile the near-normal temp w/NMS, but there is too much concerning to keep her on haldol, I think. Also, I see that haldol is contraindicated w/BG lesions, which I didn't know before. We'll d/c and see what else we can do.
 
how high was the ck?

I think stopping haldol is a good idea.

agree with ativan. You should probably be monitoring her in an ICU setting. could be alcohol withdrawal, serotonin syndrome.

Have you done an LP?
 
It's a little late, but give some aspirin and call neuro. Sounds like a CVA.

Withdrawal dyskinesia can be a tricky animal, but this doesn't sound like it.

Unilateral weakness, clonus...all signs of stroke. Fever occurs in about 1/4.

Call neuro.
 
Agree with Anasazi. Whether or not he is right or wrong, you got to eliminate the worst off the list first--NMS or stroke. If it turns out not to be stroke fine, you but got to investigate it first to at least rule it out.
 
thanks for all the great replies.

She is now 3 days out - we did initially treat for CVA with ASA + supportive care, since phys exam and CT suggested ischemic stroke; she presented 18 hrs after event, too late for TPA. Still has e/o CVA with some R-sided weakness and flat Babinski on that side. She is in step-down, with ICU nurses and near-ICU-level care (all but the vent).

The hyperreflexia and clonus got progressively worse, AMS progressively worse, CK 918 (not clear on interp since I understand can also be elevated in CVA), increasing WBC, very slowly increasing temp, diaphoresis, flushing. I read the ddx for NMS vs serotonin and hadn't realized that you can get an atypical NMS without rigidity or high temp.

I think an LP is a good idea, but at this point I don't know how I could sedate her heavily enough to do it, without risking having to intubate. She won't tolerate much at all and is moving around a lot. I guess maybe one could go to ativan drip as if treating EtOH w/d.

thanks again.
 
thanks for all the great replies.

She is now 3 days out - we did initially treat for CVA with ASA + supportive care, since phys exam and CT suggested ischemic stroke; she presented 18 hrs after event, too late for TPA. Still has e/o CVA with some R-sided weakness and flat Babinski on that side. She is in step-down, with ICU nurses and near-ICU-level care (all but the vent).

The hyperreflexia and clonus got progressively worse, AMS progressively worse, CK 918 (not clear on interp since I understand can also be elevated in CVA), increasing WBC, very slowly increasing temp, diaphoresis, flushing. I read the ddx for NMS vs serotonin and hadn't realized that you can get an atypical NMS without rigidity or high temp.

I think an LP is a good idea, but at this point I don't know how I could sedate her heavily enough to do it, without risking having to intubate. She won't tolerate much at all and is moving around a lot. I guess maybe one could go to ativan drip as if treating EtOH w/d.

thanks again.

1. What iso-enzyme of CPK is raised? it could give you a clue, though the mild raise as in your case is uncharacteristic of NMS.
2. WBC could be increasing for myriad of reasons: the pt being on ICU is not the last of them (?UTI ?chest inf ?CVA by itself ?NMS)
3. I am not sure what LP results would give you at this stage. My understanding is the only benefit of doing it would be to rule out meningitis/ecephalitis. Is the pt on any abx already? broad spectrum/acyclovir? The MRI may be -ve in herpes simplex encephalitis within the first 24-48 hrs, but attenuation may become evident later on. I would consider re-imaging if you suspect that as DDx. If she is not on abx, she would probably be dead by now with meningitis. so, again, what is the point of an LP?
 
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