Neuroleptic malignant syndrome in the trauma intensive care unit: Diagnosis and management of a rare disease in a challenging population

Abstract

Neuroleptic malignant syndrome (NMS) is a life-threatening neurological disorder associated with the use of antipsychotic medications. Many of its classic signs, such as fever and altered mental status, are nonspecific in trauma intensive care unit (ICU) patients, and its rarity makes it a difficult diagnosis in this population. However, delays in treatment can be costly both in terms of hospital resources and patient outcomes. We herein report a case of a 54-year-old trauma patient with NMS precipitated by a combination of cocaine withdrawal and neuroleptic medications. Few cases of NMS in the intubated polytrauma patient have been described in the literature previously. Given the poor outcomes associated with this disorder, ICU patients would benefit from risk stratification and avoidance of neuroleptic medications in those at highest risk for NMS, particularly patients who are withdrawing from dopaminergic agents.

Emergent Treatment of Neuroleptic Malignant Syndrome Induced by Antipsychotic Monotherapy Using Dantrolene

“…Whereas dantrolene is commonly used for spasticity and malignant hyperthermia by ED providers, neurologists and intensivists favor bromocriptine as the medical therapy for management of NMS. This change in medical therapies used for NMS management during a hospital course has been reported previously 1,11…”

“…Recent literature suggests that both diagnosis and treatment of NMS remain challenging 11,18. While NMS is primarily recognized by hyperthermia and peripheral muscle rigidity, presentation can often vary.…”

“…There are a growing number of case reports on NMS, likely in relation to the ongoing use of antipsychotic monotherapy (Table 2). 1,7,11–17 We present two cases of NMS induced by antipsychotic monotherapy treated with dantrolene in the emergency department (ED). Both cases were approved by the Arrowhead Regional Medical Center Institutional Review Board.…”

Development of Atypical Neuroleptic Malignant Syndrome After Treatment of Cocaine Intoxication: A Case Report and Literature Review

“…A comparative study of 166 psychiatric patients with and without substance use history treated with antipsychotics revealed that four or 5.1% of cocaine users developed NMS compared to none of the non-cocaine users [ 14 ]. One report described a case of NMS with lead-pipe rigidity in the setting of recent cocaine use by a chronic cocaine user with long-term antipsychotic treatment [ 15 ]. Another case of classic NMS was due to cocaine use that occurred in the absence of antipsychotic medications [ 16 ].…”

Neuroleptic Malignant Syndrome: A Potential Etiology of Multisystem Organ Failure in a Burn Patient

“…1 NMS is a clinical diagnosis manifested by a spectrum of symptoms, including the tetrad of hyperpyrexia, rigidity, autonomic instability, and altered consciousness. 1,2 The diagnosis of NMS consists of an elevated creatine kinase greater than 4 times the upper limit of normal is consistent with NMS, 1 and a creatine kinase level >10 000 U/L may be useful in the diagnosis of NMS. 3 Patients may also present with leukocytosis, hepatic failure, renal failure, and heart failure, as well as broad electrolyte disturbances, including hypocalcemia in the absence of infections or other known causes.…”