# Benadryl & Dystonic Reactions



## ResTech (Sep 27, 2008)

I have been wondering this for some time and tonight while bored at work, I decided to research it without much luck.

I had a call once for seizures and when we arrived it looked like a scene from the movie The Exorcist. The pt. was laying on the bed in an upstairs bedroom flailing about violently and uncontrollably. I have never seen anything like it before. It was obvious this was not seizure activity as the pt. was conscious and able to talk (more like cry and yell and express her fear and pain).

The pt. had a hx of schizophrenia and several other mental disorders and was being treated at a specialty hospital for her mental issues. Pt. had been placed on new meds (don't remember specific) for the schizophrenia within the past few days. 

The PHRN on the medic unit arrived and suspected a dystonic reaction and called medical command who ordered diphenhydramine.... which did not work. The RN then administered Ativan which was successful in controlling the muscle reaction but never fully stopped it. 

I know in many cases benadryl is indicated for treating extrapyramidal reactions and works successfully... what is its mechanism of action when used to treat EPS? And what doses are usually required?

Any info is appreciated. Thanks!


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## mycrofft (Sep 27, 2008)

*Maybe this is two in one*

 Wonder why Ativan worked but not Benadryl? 
Not sure about neuromuscular props of diphenhydramine, the article I saw was not well documented. Ask a pharmacist, they like people who say please and thanls and not just gimme.

Is there a possibility this episode was hysteric or attention-getting?


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## ResTech (Sep 27, 2008)

No it wasn't voluntary at all... this patient was in her upper 40's or 50's I believe and she has been undergoing care for a long time. Her husband was there as was other family... all which were frustrated by all the doctors and meds they have tried to try and help the pt.


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## Flight-LP (Sep 28, 2008)

The anticholinergic properties of medications such as Benadryl or, even better, Cogentin, does work wonderfully for ERS symptoms. However, many neuroleptic medications require more than just the anticholinergic properties. Most 1st generation neuroleptic agents, especially the phenothiazine family (Compazine, Phenergan, Thorazine, Mellaril), strongly block the dopamine receptors in the brain. As such, agents that slow the central nervous system as a whole are needed. This is where your benzo's come into play. Versed especially can be helpful since it acts directly on the GABA receptor and it is not as lipid-soluble as Diazepam, therefore it is more potent and last longer.

Current trends in psychiatry are showing a reduction of first generation neuroleptics and moving towards more favorable, and more controllable 2nd or 3rd generation medications.

For those that are just way out there and truly require the 1st generation phenothiazines are also being prescribed anti-parkinson agents such as Sinemet to counteract the known side effects. Some are also receiving old school beta-blockers, Inderal in particular, which has shown to be successful.

EPS is no joke. In more severe forms it can cause Akathisia which can worsen psychosis and is also known to cause diabetic ketoacidosis. I have even had to RSI some more serious cases as the only way to stop their activity. Severe EPS isn't a pretty site, I can't imagine the life some of those folks live..............................


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## Flight-LP (Sep 28, 2008)

Flight-LP said:


> The anticholinergic properties of medications such as Benadryl or, even better, Cogentin, does work wonderfully for ERS symptoms. However, many neuroleptic medications require more than just the anticholinergic properties. Most 1st generation neuroleptic agents, especially the phenothiazine family (Compazine, Phenergan, Thorazine, Mellaril), strongly block the dopamine receptors in the brain. As such, agents that slow the central nervous system as a whole are needed. This is where your benzo's come into play. Versed especially can be helpful since it acts directly on the GABA receptor and it is not as lipid-soluble as Diazepam, therefore it is more potent and last longer.
> 
> Current trends in psychiatry are showing a reduction of first generation neuroleptics and moving towards more favorable, and more controllable 2nd or 3rd generation medications.
> 
> ...



Whoops, typo........................works wonderfully for EPS symptoms, not ERS. Sorry..........


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## mikie (Sep 28, 2008)

Well this is all learning for me, I didn't even know Benadryl was indicated for this.  I always thought of it as the antihistamine.


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## maksim (Sep 28, 2008)

I saw a heavy poisoning with it benadril. 
Coma, atetosis, and a myodistonia.
So, it can


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## paccookie (Oct 2, 2008)

mikie333 said:


> Well this is all learning for me, I didn't even know Benadryl was indicated for this.  I always thought of it as the antihistamine.



It also works decently as an antiemetic.


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## q7t1 (Feb 23, 2014)

Sorry to necro but I too have found this indication for Benadryl on a recent incident that was almost exactly like OP's


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## STXmedic (Feb 23, 2014)




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## mycrofft (Feb 23, 2014)

Looking back five and a bit years ago:
I've seen dystonic reactions addressed with benedryl work well.
I have never seen a dystonic reaction where the pt is "thrashing around". It more reminded me of the writhing you see with hyperventilation, plus wry neck. NOT energetic at all.

I again wonder if the described episode was not hysteric or something else which a tranquilizer/benzo addressed…such as pt seeking it?


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## abckidsmom (Feb 23, 2014)

mycrofft said:


> Looking back five and a bit years ago:
> I've seen dystonic reactions addressed with benedryl work well.
> I have never seen a dystonic reaction where the pt is "thrashing around". It more reminded me of the writhing you see with hyperventilation, plus wry neck. NOT energetic at all.
> 
> I again wonder if the described episode was not hysteric or something else which a tranquilizer/benzo addressed…such as pt seeking it?



Thinking of the patient population, the drama potential is high.  I've seen plenty of dystonic reactions where the patient was just having their dyskinesia and needing help, and then I've seen a handful where the patient was over the total top with the drama and hysterical thrashing.  

It could go both ways.


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## mycrofft (Feb 24, 2014)

abckidsmom said:


> Thinking of the patient population, the drama potential is high.  I've seen plenty of dystonic reactions where the patient was just having their dyskinesia and needing help, and then I've seen a handful where the patient was over the total top with the drama and hysterical thrashing.
> 
> It could go both ways.



Dang it, you're right.:mellow:  I forget that just because you haves mental illness or a drug reaction doesn't mean you can't be over-dramatic as well! Thanks.


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## 18G (Mar 11, 2014)

I observed an 8 y/o during my Paramedic clinicals who came into the ED with a dystonic reaction. The PA gave Benedryl and the patient resolved almost immediately. Dad reported that his son was started on a "new ADHD medication" that morning.


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## Carlos Danger (Mar 11, 2014)

I once gave 25mg promethazine and fentanyl to a woman on a long helicopter ride. 10 minutes later she's contorted and writhing all over the stretcher. Classic dystonia.

50mg of diphenhydramine and she stopped moving and slept like a baby.


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## 18G (Mar 11, 2014)

Benedryl is an amazing little drug.


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