Tasty Morsels of EM 056 – Dystonic reactions

14 Aug

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.


[Video via Larry Mellick’s excellent youtube channel]

Anyone working in any ED for any length of timee will have seen this – either from someone using an illicit substance and appearing at triage or in a poor young woman, 30 mins after your treatment for her migraine.

  • common with anti-emetics (metoclopramide/prochlorperazine) and anti-psychotics though the full list of potentials is huge.
  • pathophysiolgy is to do with dopamine in the basal ganglia (blockade of central dopaminergic receptors and some other mechanisms I struggle to follow)
  • Harwood-Nuss has a nice table of associated agents
    • drugs that might be used illicitly: cocaine/ketamine/bupropion/dextromethorphan
    • bizzarely both diphenhydramine and diazepam, (agents that are often used to treat dystonia) are on the list. Even propofol gets a mention
  • Tardive dyskinesia is more severe and usually with long term use of anti psychotics
  • drug or alcohol abuse is thought to be a predisposing factor
  • Look at the mandible the neck and the eyes – these are the commonest areas affected. Can affect the whole body
  • reactions can be delayed up to 5 days if starting a new drug
  • give an antimuscarinic to fix it
    • where I’ve worked this has always been procyclidine
    • elsewhere diphenhydramine and benztropine are commonly suggested agents
  • IV route seems to be significantly quicker in action than IM.
  • Harwood-Nuss suggests oral meds for a few days to prevent recurrence


Harwood-Nuss 5th Edition, pg 1501

[featured image CC license, Wikimedia Commons, James Heilman, MD]

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