Have you guys seen nms?

[Merely]

How rare is this? Do you manage on psych floor or send somewhere?

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[Old&InTheWay]

I saw a case on my psych Sub-I. Pt was managed on a medical unit until medically stable then transferred to inpt psych unit. He was pretty psychotic and we we held him for 2 weeks before restarting antipsychotics. But apparently is pretty rare. This was a kid with newly diagnoses schizophrenia whose family was, for cultural reasons, not understanding/accepting of the dx or treatment and was going on and off of his meds (including incorrectly high doses).

 

[wolfvgang22]

How rare is this? Do you manage on psych floor or send somewhere?

It is rare, thankfully. I have seen NMS several times. Malignant catatonia and NMS can be hard to distinguish, having seen both. Most often I have seen NMS working consultation and liaison cases on the inpatient medicine floor.

You are more likely to see NMS in the seriously mentally ill population who take a lot of antipsychotics, obviously. NMS is managed in the ICU most of the time. Patients with NMS must be admitted to the medical hospital. Rhabdomyolysis and subsequent renal failure is usually an important concern with NMS, as well it is with severe catatonia. Of course, you have the fever, as well. Most of the time patients who have suffered NMS are placed on clozapine, as we are often able to use less clozapine to control psychosis compared to massive doses of risperdal or other antipsychotics, that caused the NMS in the first place. Overdose with risperdal has been the chief cause of NMS in my experience. Used to see it a lot with Geodon, but Geodon became less popular. Clozapine can also cause NMS, but if the patient needs less antipsychotics then NMS is less likely.

 

[Taddy Mason]

I saw NMS during my sub-I last year in a Geri pt. who, if I remember correctly, had Lewy Body dementia with significant behavioral issues. He had previously been on Geodon but switched to Risperdal recently. The patient was managed on the Geri psych unit, but for political reasons, which resulted in 2 physicians who refused to accept the patient at the hospital we had tried to transfer the patient to, to be let go.

 

[hallowmann]

Seen it in person 2-3 times. Almost exclusively on a general medical or Med-Psych floors. Seen a handful of patients on Psych floors after they've suffered from it and become medically stabilized.

 

[clausewitz2]

It is rare, thankfully. I have seen NMS several times. Malignant catatonia and NMS can be hard to distinguish, having seen both. Most often I have seen NMS working consultation and liaison cases on the inpatient medicine floor.

You are more likely to see NMS in the seriously mentally ill population who take a lot of antipsychotics, obviously. NMS is managed in the ICU most of the time. Patients with NMS must be admitted to the medical hospital. Rhabdomyolysis and subsequent renal failure is usually an important concern with NMS, as well it is with severe catatonia. Of course, you have the fever, as well. Most of the time patients who have suffered NMS are placed on clozapine, as we are often able to use less clozapine to control psychosis compared to massive doses of risperdal or other antipsychotics, that caused the NMS in the first place. Overdose with risperdal has been the chief cause of NMS in my experience. Used to see it a lot with Geodon, but Geodon became less popular. Clozapine can also cause NMS, but if the patient needs less antipsychotics then NMS is less likely.

I kind of am persuaded by Max Fink's argument that NMS is just iatrogenic catatonia. Agreed that this is a "transfer to ICU" condition. NMS has been documented associated with abrupt clozapine withdrawal as well, so there's that.

 

[ryerica22]

I kind of am persuaded by Max Fink's argument that NMS is just iatrogenic catatonia. Agreed that this is a "transfer to ICU" condition. NMS has been documented associated with abrupt clozapine withdrawal as well, so there's that.

Makes it even more confusing as to etiology. I've been told that NMS is not always dose dependent but can be due to rapid titration? We often assume that risk when we have to rapidly titrate on the inpatient unit.

 

[Crayola227]

Quick wiki review says 10% mortality

You get autonomic instability - that's why you get fever, and and unstable blood pressure is just as good a reason for the ICU as any

never mind how muscle rigidity can lead to impaired ventilation, you can see hypoxic brain injury as you could with prolonged sz

my understanding as well, is that once you identify NMS, even if it seems "mild," there is no telling what the course will be

get that person to where emergent airway management is on the table, RR and coding is more available even if they just go to the floor

I could be wrong, but I was taught not to mess around with NMS

on the point about fever, fever 2/2 purely central causes and not just FUO or suspected infection, is a REALLY concerning sign

once you've so affected just the brain that you're messing with basic vital signs like RR, HR, O2 sat, temp, BP.... um, I find that very highly concerning

so even getting a fever on one of these psych drugs, in the wrong context, makes me take a big pause at least

 

[Crayola227]

vitals are vital, man

 

[Merely]

vitals are vital, man

You are quite peculiar lol you write the longest posts I’ve ever seen in every forum haha thanks for giving back

 

[liquidshadow22]

How rare is this? Do you manage on psych floor or send somewhere?

manage on the psych floor ?

 

[st2205]

manage on the psych floor ?

You certainly can manage it on the psych floor. You manage it by getting them off the floor.

 

[Sushirolls]

I've seen 2 in the ICU on C/L service as resident, positive outcomes for both. NMS=ICU level care.

One as staff doc, after the NMS resolved. Was treating patient for Catatonia, originally suspected as related to zyprexa for young male with schizophrenia. This case furthered my personal support/suspicion of the overlap of NMS and Malignant Catatonia. The patient required ECT daily, and I was able to pull strings to make M-Th happen. Very briefly the patient on the psych unit mid ECT course had some Tachycardia but no other symptoms. Had standing orders to page if any other symptoms developed to immediately transfer to ICU. Pre-alerted the ICU docs about the patient as a courtesy. Was able to resolve the catatonia. However had quick relapse on discharge and required a second course. Patient was also refractory to a thorough benzo trial.

Also of interest was during the benzo tapering that overlapped with the acute ECT series, the pre treatment of Flumazenil actually contributed to a quick/brief seizure just before the ECT stimulus. Patient had not yet been on benzos of a duration to suspect a physiologic dependence. Nor had the flumazenil yet reached peak circulation. De novo seizures are not therapeutic, and the stimulus was promptly delivered with a quality seizure ensuing. No sequalae, no future events with flumazenil use, and eventually did get off the ativan benzo trial. This has been the only case I've witnessed a pre-seizure before ECT stimulus.

 

[clausewitz2]

I've seen 2 in the ICU on C/L service as resident, positive outcomes for both. NMS=ICU level care.

One as staff doc, after the NMS resolved. Was treating patient for Catatonia, originally suspected as related to zyprexa for young male with schizophrenia. This case furthered my personal support/suspicion of the overlap of NMS and Malignant Catatonia. The patient required ECT daily, and I was able to pull strings to make M-Th happen. Very briefly the patient on the psych unit mid ECT course had some Tachycardia but no other symptoms. Had standing orders to page if any other symptoms developed to immediately transfer to ICU. Pre-alerted the ICU docs about the patient as a courtesy. Was able to resolve the catatonia. However had quick relapse on discharge and required a second course. Patient was also refractory to a thorough benzo trial.

Also of interest was during the benzo tapering that overlapped with the acute ECT series, the pre treatment of Flumazenil actually contributed to a quick/brief seizure just before the ECT stimulus. Patient had not yet been on benzos of a duration to suspect a physiologic dependence. Nor had the flumazenil yet reached peak circulation. De novo seizures are not therapeutic, and the stimulus was promptly delivered with a quality seizure ensuing. No sequalae, no future events with flumazenil use, and eventually did get off the ativan benzo trial. This has been the only case I've witnessed a pre-seizure before ECT stimulus.

Great post, always good to get more anecdata. I am curious about the assertion that de novo seizures are not therapeutic. ECT (and chemo convulsive therapy before that) was originally motivated by the observation that many psychiatric symptoms seemed to improvw after spontaneous seizures. There is also the "forced normalization" epilepsy literature suggesting increase in psychotic symptoms following resolution of epileptiform EEG activity in folks with comorbid epilepsy (or schizophrenia-like psychosis of epilepsy depending on how you look at it). Has anyone actually examined spontaneous seizures in catatonia/NMS?

 

[Dharma]

Rare. Over-diagnosed by primary teams. In CL, when primary teams call it NMS, we roll in and ~9/10 times say no. Most often catatonia, encephalitis, serotonin toxicity. Good keep on the look out for it though.

 

[Crayola227]

You are quite peculiar lol you write the longest posts I’ve ever seen in every forum haha thanks for giving back

As a 3rd yr med student, I was prerounding on patients on the list, one by one by one. So it wasn't until 45 min after I got there, when the resident arrived, that the resident says to me, "Did you see that Mr. Jones was in afib with RVR in the 170s when you got here?"

Uh, shyte, no I didn't, because I'm slow when I pre-round, and he was last on my list....

So the resident said, "When I first get to work, the first thing I do is check the current vitals on every patient, so I know they're not actively dying while I do the rest of my pre-rounding."

OK, that sounds like a good idea. Would have been awesome to think about it myself, but I'm a 3rd yr so I'm lucky if I can find my own butt when I wipe.

They quipped, "Vitals are vital. They're called vital signs for a reason."

That was a pearl that always stuck with me for being catchy, I suppose. It seems silly, but given the number of times I've had reason to quip it to someone who graduated medical school, I still think it's clever. Sometimes we need the reminder how important those values are to life at its most basic level.

Case in point, psych or not, abnormal vitals, I mean, a slight fever can seem like no big deal, but homeostasis is so good, that once someone gets outside that range, they are having a real disruption in their bodily systems and it's a point to take notice.

It's tough because in a medical setting, vital signs derangements become the norm, so it can predispose one to not taking that "little fever" or tachy or whatever, seriously enough.