Neuro Question (Clinical)

[Medic248]

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Hey all,
I'm a Paramedic in Pittsburgh, PA, and just came across a patient with tardive dyskinesia, and had a quick question: (forgive me if I'm in the wrong forum)

This is a 32 YOF who was having "stomach problems" at the beginning of last year, and after a gastric emptying test, she was prescribed Reglan. Due to the Black Box warnings, her and her physician decided to discontinue the Reglan (stomach problems have since spontaneously resolved). In May of last year, she experienced an episode of twitching, which her doc thinks is TD. She hasn't had any symptoms until today, when she had an episode lasting about 40 minutes. We showed up part-way into this episode, and she said that Benadryl helped her last time, so I went with 50mg IV. As I was drawing up the Benadryl, she suddenly returned to normal, and said she didn't want the Benadryl if she was better. No sooner had I labeled the syringe and put it aside, did she start twitching again. I gave her the Benadryl, and this 2nd episode lasted about 4 minutes and was less severe (upper extremities and face only, as opposed to upper/lower and face for the 1st episode). She had 2 more episodes, lasting about 2 minutes and 30 seconds.

I'm vaguely familiar with TD, and just looked up again, but I'm failing to see the connection between 1) her stopping the Reglan nearly a year ago, 2) this episode, 3) the effect/benefit of Benadryl, 4) why the episodes were less severe and shorter in duration after Benadryl (or just coincidence). I was under the impression that this was a side-effect of taking the medication, not a delayed withdrawl symptom. Is Benadryl a good treatment for acute instances of TD, or would a benzo (e.g., diazepam) be a better option?

Thanks!

 

[seasurfer]

Hey all,
I'm a Paramedic in Pittsburgh, PA, and just came across a patient with tardive dyskinesia, and had a quick question: (forgive me if I'm in the wrong forum)

This is a 32 YOF who was having "stomach problems" at the beginning of last year, and after a gastric emptying test, she was prescribed Reglan. Due to the Black Box warnings, her and her physician decided to discontinue the Reglan (stomach problems have since spontaneously resolved). In May of last year, she experienced an episode of twitching, which her doc thinks is TD. She hasn't had any symptoms until today, when she had an episode lasting about 40 minutes. We showed up part-way into this episode, and she said that Benadryl helped her last time, so I went with 50mg IV. As I was drawing up the Benadryl, she suddenly returned to normal, and said she didn't want the Benadryl if she was better. No sooner had I labeled the syringe and put it aside, did she start twitching again. I gave her the Benadryl, and this 2nd episode lasted about 4 minutes and was less severe (upper extremities and face only, as opposed to upper/lower and face for the 1st episode). She had 2 more episodes, lasting about 2 minutes and 30 seconds.

I'm vaguely familiar with TD, and just looked up again, but I'm failing to see the connection between 1) her stopping the Reglan nearly a year ago, 2) this episode, 3) the effect/benefit of Benadryl, 4) why the episodes were less severe and shorter in duration after Benadryl (or just coincidence). I was under the impression that this was a side-effect of taking the medication, not a delayed withdrawl symptom. Is Benadryl a good treatment for acute instances of TD, or would a benzo (e.g., diazepam) be a better option?

Thanks!

We need to go back to basic. We cannot presumed it is TD until we rule out other causes.

May I ask you a few questions?

1. What is all her vital signs?

2. How is a her physical exam, did you do complete neurological exam? Did you guys perform a fundus exam?

3. Dose she has any electrolytes abnormality?

4. Does she has a history of seizure or family history of seizure?

5. What are her other past medical history, this is very important?

6. What other medical did she take?

7. Does she has any psychiatric history?

Lastly, if I were you, I wouldn't focus on TD and miss out the other things. She could be having something wrong going on, so try no to just focus on the TD.

 

[Head]

Better questions to ask would be: was she clutching a teddy bear and was there a service dog there with her?

This smells much more like psychogenic disease than tardive dyskinesia. A movement disorders expert would be much better at answering some of your specific questions, but I can take a crack at it. Tardive dyskinesia, once it starts tends to be much more of a chronic issue, something the patient deals with every day. It usually involves choreoathetoid (snakelike writhing) movements primarily in the face and mouth, but can also involve the limbs. Rarely the patients can have tics. Again, this would occur nearly every day and not just in very isolated episodes like this woman describes. The medications available frankly aren't very effective at treating the symptoms. It is not uncommon for the symptoms to start months after the offending agent has been stopped. Tardive dyskinesia is now fairly rare since the 2nd generation antipsychotics are less likely to cause it. I've had only one patient with this. So if it's not tardive dyskinesia, what could it be? It's not seizure, because if you witnessed twitching on both sides a seizure would make her unconscious. It could be some other movement disorder or myoclonic jerks, but again isolated episodes would be very unusual. Most likely this is a manifestation of Psychiatric disease. Sometimes physicians call it something real because telling the patient they are faking it makes things worse instead of better.

Here's another patient who was told she has "dystonia". You be the judge.

http://www.youtube.com/watch?v=cEN5KGwNGeo

 

[ask1288]

malingering / factitious disorder would be high on the differential

 

[Medic248]

May I ask you a few questions?

1. What is all her vital signs?
HR:120 (Sinus Tach /s ectopy), RR:18; BP:140/100, SpO2: 100%

2. How is a her physical exam, did you do complete neurological exam? Did you guys perform a fundus exam?

This is a 32 year old female with a history of tardive dyskinesia who called today after a flare-up of symptoms. She states she began taking Reglan in early 2009 for unspecified "stomach problems", and shortly discontinued this medication after speaking with her physician about the Black Box warnings. Shortly after, in May/June of 2009, she experienced a similar episode of convulsions, which her physician states he believes is tardive dyskinesia. She reports this was successfully treated with diphenhydramine, and requests the same medication today.
Upon assessment, she appears in moderate distress, and is convulsing uncontrollably. She is, however, able to ambulate and answer questions. Medical command was consulted (Dr. XXXXX) in regards to the benefit of diphenhydramine in this situation. He was uncertain of any benefit from diphenhydramine, but he did agree that if it has helped in the past, it is worth a try, as it is a benign medication. During this discussion, she was assisted to the ambulance and secured on the stretcher in the usual fashion. Vital signs were measured and recorded as: HR:120;BP:140/100;SpO2:100%. An 18ga IV was established in her right AC and normal saline administered at 125ml/hr. At this point, her convulsions stopped suddenly, and she returned to normal. She denies all symptoms at this point. After about 5 minutes, the convulsions started again, and diphenhydramine 50mg IVP was administered. The convulsions stopped suddenly again after about 4 minutes. She had two more episodes of convulsions, each lasting less than a minute, just prior to arrival at ED and again upon transfer to bed. Each of these episodes begins with her stuttering, then progresses downward. The first and last episodes involved both upper and lower parts of her body; however, the other two episodes involved only her arms, shoulders and head/neck.

Physical Exam:
Head: NC/AT. PERRLA, EOMI without nystagmus.
Neck: Supple, non-tender. Jugular veins flat. Trachea midline.
Chest: Atraumatic. Good inspiratory effort without wheezes, rales or rhonchi.
Abd: Soft. Denies pain. Physical exam deferred.
Extrem: Moves all well between episodes. Radial pulses +2 b/l.

Neuro: CN II-XII intact by exam. (Performed between episodes) She is neurologically intact with the exception of the above findings.

3. Dose she has any electrolytes abnormality?

Unable to assess this in the field.

4. Does she has a history of seizure or family history of seizure?

She is otherwise healthy, family history did not include seizures or other neurological problems and wasn't further elicited.

5. What are her other past medical history, this is very important?

Hx of GERD (resolved) and TD.

6. What other medical did she take?

No current medications, except for occasional PRN OTC tylenol, motrin, etc.

7. Does she has any psychiatric history?

Denies.

Lastly, if I were you, I wouldn't focus on TD and miss out the other things. She could be having something wrong going on, so try no to just focus on the TD.