Can IM chlorpromazine cause an elevation in CK?

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Kuvan

Kuvan

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Pt was given IM chlorpromazine, IM Benadryl, IM midazolam. His CK is elevated. I read something about agents administed IM-ly can cause an elevation in CK.

Thanks,
 
This guy has been to multiple mental health. He doesn't sleep. He runs around the unit, grunting, trying to provoke other patients. He's not restrained. He slept for a few hours after his IM meds. Then the cycle starts again. No autonomic instability, no muscle rigidity, I think his temp was a bit elevated but coming down. Pt's mom claimed that pt is allergic to ativan, olanzapine, haldol and other meds. So, had to go with midazolam and chlorpromazine.
 
If he's psychomotorically agitated and constantly moving, that in and of itself can cause a mild elevation in CK. Are we talking a CK of 200-300 or in the thousands? If the former, I doubt that it is medication-related. If the latter, that's more concerning.

Typically NMS is more strongly associated with the high potency antipsychotics, so I wouldn't expect that chlorpromazine would do much. But anything is possible, I suppose.
 
Kuvan said:
Pt's mom claimed that pt is allergic to ativan, olanzapine, haldol and other meds. So, had to go with midazolam and chlorpromazine.
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What kind of allergic reaction? In psych, patients typically report side effects as allergies to avoid them. It would be beneficial to know if it is a true allergy or not. At some facilities, lorazepam may be the only IM option for seizures. I’d need a contingency plan if a true allergy.

What level of CK elevation?
 
His CK is 2000 something. I'm off today but I saw the labs and it's 2000 something. Puzzling.
 
The 2000 should sound off concern but doesn't mean it's NMS. Working out and exercising could increase it to that level. Sometimes in NMS you could've caught the CK at a moment where it's still rising. Keep it and his vitals monitored avoid antipsychotics just in case if possible.

BTW I had a case in medschool where CK was of concern and my resident who was teaching me had me look up CK levels in relation to various activities. It taught me something important that I had to rely upon later that most physicians I saw didn't know about before.

 
I'd worry more about causing severe hypotension with IM Thorazine than elevated CK. Let us know how this plays out though!
 
Thank you guys! Much appreciated. I'll let you guys know how it plays out. The provider told me yesterday that the pt came in with elevated CK but it was trending down. But we had a discussion maybe to hold off on IM chlorpromazine.
 
whopper said:
The 2000 should sound off concern but doesn't mean it's NMS. Working out and exercising could increase it to that level. Sometimes in NMS you could've caught the CK at a moment where it's still rising. Keep it and his vitals monitored avoid antipsychotics just in case if possible.

BTW I had a case in medschool where CK was of concern and my resident who was teaching me had me look up CK levels in relation to various activities. It taught me something important that I had to rely upon later that most physicians I saw didn't know about before.

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Thank you for the info! 🙂
 
downwithDTB said:
Rigidity? Reflexes? Bush Francis?
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No rigidity or hyperreflexia. When the IM midazolam/IM benadryl/IM chlorpromazine wore off, he went back to running around the unit, grunting and provoking other patients.
 
Was the test with differentiated isoenzymes, or just total?

I know I'm not a doctor or even a medical student or anything, but personally I've never understood doing total CK without the breakdown. It seems to invite more questions if the result is elevated as it could indicate a cardiac or pulmonary process.
 
Again not a doctor etc, but not sure why they would do a test that doesn't rule anything in or out. CK used to be used before troponin was available to evaluate chest pain. At least the isoenzyme test could give some clarity. If I were a doctor, and I'm not, I would do an isoenzyme test and troponin. And yes I know troponin rises and falls, but it does stay elevated for up to a couple of weeks and whatever is causing the patient's CK to stay high is ongoing. It might not be likely, but on the other hand once you do a test that shows there is muscle break down but can't specify from where, it seems like you've opened a can of worms.
 
birchswing said:
Again not a doctor etc, but not sure why they would do a test that doesn't rule anything in or out. CK used to be used before troponin was available to evaluate chest pain. At least the isoenzyme test could give some clarity. If I were a doctor, and I'm not, I would do an isoenzyme test and troponin. And yes I know troponin rises and falls, but it does stay elevated for up to a couple of weeks and whatever is causing the patient's CK to stay high is ongoing. It might not be likely, but on the other hand once you do a test that shows there is muscle break down but can't specify from where, it seems like you've opened a can of worms.
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You wouldn’t do anything cause you’re not a doctor. You can feel free to leave the responses to people who actually interpret these labs in real life.
 
calvnandhobbs68 said:
You wouldn’t do anything cause you’re not a doctor. You can feel free to leave the responses to people who actually interpret these labs in real life.
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this makes no sense, the guy asked a reasonable question after doing research, instead of telling him hes not allowed to ask a question you could simply explain where he has a misunderstanding
 
Why did you check CK in the first place? Now you’re having to spin about this lab value that may not even mean anything.
 
lyla said:
Why did you check CK in the first place? Now you’re having to spin about this lab value that may not even mean anything.
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In our ED, patients that are psychomotorically agitated and clearly psychotic will often have a CK checked. I'm not sure if that's the situation here, but it's something that we have to deal with not uncommonly. Of course, a CK less than 2000-3000 doesn't get the ED docs excited, but unfortunately stand-alone psychiatric hospitals get freaked out about anything with a red exclamation point next to it, even if the values are trending down.
 
NickNaylor said:
In our ED, patients that are psychomotorically agitated and clearly psychotic will often have a CK checked. I'm not sure if that's the situation here, but it's something that we have to deal with not uncommonly. Of course, a CK less than 2000-3000 doesn't get the ED docs excited, but unfortunately stand-alone psychiatric hospitals get freaked out about anything with a red exclamation point next to it, even if the values are trending down.
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CK levels if anything are underchecked, particularly when there is any reason to be suspicious for NMS or catatonia. Sure you will pick up a lot of elevated values that you can simply trend down, but missing these diagnosis or giving too little fluid can result in much worse harm then a few extra lab draws that cost a few bucks.
 
birchswing said:
Again not a doctor etc, but not sure why they would do a test that doesn't rule anything in or out.
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Because there's no reason to. We don't even know why the OP got a CK in the first place, but sometimes, the reason to get a CK is if you suspect NMS. So say you suspect NMS, the elevated CK may lead you toward that diagnosis but it's certainly not definitive. You need to look at other symptoms/labs/vitals. There are a lot of things in medicine where you need to use clinical judgment rather than wasting time and money on unnecessary labs, such as a breakdown of CK.
 
OK, this is what I got from looking at the labs again this morning. 11/14 - CK 2158. CK-MB fraction 7.48 ng/ml and % CKMB 9.5%. They were checked coz the pt went from one mental health to another and ended up at a hospital with elevated CK and acute kidney failure and was ventilated. I was told he was very agitated at the hospital every time they took him off of the ventilator, so they had to give him precedex and propofol. Then he was discharged and he came to our mental health. That's why the provider got the CK again. When he got to our hospital, he didn't sleep for a day. Don't know how many days he hadn't slept before he got there. Like I said before, his mom told the provider he couldn't take this and that, so the provider was limited to chlorpromazine, IM midazolam (just so he would get a few hours of sleep) and IM benadryl. He would run around the unit, grunting, and trying to provoke other patients when the IM midazolam wore off. He was agitated and moving constantly. I guess over the weekend, his Lithium and Depkote were DC'ed (he was refusing them anyway) and was put on Haldol. He's actually mellow today, not punching or kicking the wall or counters. So, let's hope he calms down.

Oh, just got a text on the CK. We drew blood today and it's back down to 329! Yay! I guess we will go with not sleeping and psychomotor agitation. Thank you for all the replies! I learned a lot from you guys. Thanks a million!!!
 
Kuvan said:
OK, this is what I got from looking at the labs again this morning. 11/14 - CK 2158. CK-MB fraction 7.48 ng/ml and % CKMB 9.5%. They were checked coz the pt went from one mental health to another and ended up at a hospital with elevated CK and acute kidney failure and was ventilated. I was told he was very agitated at the hospital every time they took him off of the ventilator, so they had to give him precedex and propofol. Then he was discharged and he came to our mental health. That's why the provider got the CK again. When he got to our hospital, he didn't sleep for a day. Don't know how many days he hadn't slept before he got there. Like I said before, his mom told the provider he couldn't take this and that, so the provider was limited to chlorpromazine, IM midazolam (just so he would get a few hours of sleep) and IM benadryl. He would run around the unit, grunting, and trying to provoke other patients when the IM midazolam wore off. He was agitated and moving constantly. I guess over the weekend, his Lithium and Depkote were DC'ed (he was refusing them anyway) and was put on Haldol. He's actually mellow today, not punching or kicking the wall or counters. So, let's hope he calms down.

Oh, just got a text on the CK. We drew blood today and it's back down to 329! Yay! I guess we will go with not sleeping and psychomotor agitation. Thank you for all the replies! I learned a lot from you guys. Thanks a million!!!
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Thanks for the update

lol looks like the only allergy he had for Haldol was that it actually worked for his psychosis (which is probably why the thorazine wasn't working so well cause it's so low potency that sedation doses aren't super helpful as an actual antipsychotic)

Also hell yeah I'd be checking CK on this guy if he just came out of the hospital for an elevated CK and AKI.
 
Haha! Right? Oi vay! I'm glad this 22 y/o guy is doing better now.

Again, I've learned a lot from you guys. Thank you for all the replies. 🙂
 
clausewitz2 said:
I worry if this guy might actually be experiencing excited catatonia. Again, could also be raising CK. Agree that the level of elevation is critical info though
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My money is on catatonia for this one. It's not the only player but it's front and center.
 
Dharma said:
There were GABAergics in the mix and dopaminergic dysregulation could very well be a contributing factor in catatonia.
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All that review article has regarding antipsychotics (which is nothing new) is that there's mixed terrible evidence about them. Also the evidence that any type of antipsychotic would help would be an atypical bc the whole theory is that there's some? dopamine release due to the 5HT2 antagonism and weak GABA agonism. Doesn't really include Haldol anyway.

I would expect that he would have fairly quickly improved (like same day improved) with frequent IM doses of midazolam if this was catatonia. For sure it COULD have been catatonia but without very detailed info about his MSE and physical it'd be pretty hard to call that. Reason why I'm debating this is because it actually makes a treatment difference here...if this guy was actually having excited catatonia then he should be taking benzos right now.
 
calvnandhobbs68 said:
All that review article has regarding antipsychotics (which is nothing new) is that there's mixed terrible evidence about them. Also the evidence that any type of antipsychotic would help would be an atypical bc the whole theory is that there's some? dopamine release due to the 5HT2 antagonism and weak GABA agonism. Doesn't really include Haldol anyway.

I would expect that he would have fairly quickly improved (like same day improved) with frequent IM doses of midazolam if this was catatonia. For sure it COULD have been catatonia but without very detailed info about his MSE and physical it'd be pretty hard to call that. Reason why I'm debating this is because it actually makes a treatment difference here...if this guy was actually having excited catatonia then he should be taking benzos right now.
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Maybe. Catatonia is a mixed bag and we still do not understand all that much about it. Nor does it always respond to GABAergics that day either. Without seeing the guy, I cannot say much, expect going from what I have read here he likely had some catatonic features. It's missed... a lot ... and often because it's not hitting text-book features or typical responses to meds or obscured by psychosis/mania.

Pure conjecture and mental masturbation though.

Still have my dollar on catatonia ... not that it matters.

EDIT: Agree about those benzos on board still if it was excited catatonia. Hope we get an update.
 
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He's been doing very well the past few days. Night and day compared to last week. No more coding, so no IM midazolam or IM thorazine or IM benadryl. He waved and smiled at me yesterday morning. He sat and talked to another patient. However, in the afternoon, he was standing and staring blankly at the door. This morning he refused his haloperidol 5 mg but the charge nurse finally convinced him to take it. Later on, he was ok again. Not as emotionless. Very odd. But he's no longer running around, grunting, punching the wall, or provoking other patients. He's sleeping, too. But he did tell the provider that his swollen arm (from punching the wall) was due to a boa constrictor. And he told the provider that another patient was his mom. 🙁

He's just taking Haldol 5 mg qd, Haldol 2 mg PRN and trihexyphenidyl 2 mg TID PRN.
 
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