# This one stumped me



## ffemt101986 (Apr 7, 2015)

So I don't usually post anything on here but I figured this one was worthy of getting others opinions.

We were called at about 2200 for a female pt suffering from a seizure. Arrived to find a 49yo female lying in bed with uncontrolled jerking and twitching of her extremities and neck. Pt was CAOx4 and had a complaint of back pain earlier in the evening with severe back and neck pain present at the time of pt contact.  Pt has a history of depression, anxiety, Bipolar and suicidal attempts and a smorgasbord of medications to go along with it. The big ones being Haldol, lithium and Geodon.  Her husband stated there was no way she could have overdosed on any medication because they are locked up and he has had the only key on him all evening. Pt has a B/P of 156/92, Pulse of 116 strong and regular showing sinus tach on the monitor with quite a bit of artifact due to the jerking. Blood sugar of 156 and resp rate of 26 and labored and an O2 sat of 98% on room air. Im going to open myself up for criticism and admit to going all "Ambulance Driver" on this one. I did some research and think ive got it figured out and am kicking myself the *** now, but I want some other opinions.


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## STXmedic (Apr 7, 2015)

Sounds like a dystonic reaction. Hook her up with some benadryl.


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## DesertMedic66 (Apr 7, 2015)

Agreed with STX. Dystonic reactions can either be constant or be in spasms.


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## Carlos Danger (Apr 7, 2015)

Could be dystonia....or it could be serotonin syndrome, which diphenhydramine would make worse.

My other differentials include lithium toxicity, neuroleptic malignant syndrome, seizure, and psychogenesis.

Impossible to know without more information. Those are some nasty drugs. Did she have a fever? A history of seizures? Psychosis? Recent change in medication or dosage? Recent illness? Any renal problems?


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## Gurby (Apr 7, 2015)

She seems to be stable as can be, and we don't know what is going on with her... Doing nothing seems fine to me...  (and by "do nothing" I mean "do a thorough assessment, gather good history, write down all her meds, put her in the truck and drive")


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## DesertMedic66 (Apr 7, 2015)

Gurby said:


> She seems to be stable as can be, and we don't know what is going on with her... Doing nothing seems fine to me...


I'd want to try to do something about the severe back and neck pain if possible.


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## Carlos Danger (Apr 7, 2015)

Based on the little bit of info provided, I'd say that dystonia is most likely, but serotonin syndrome is a real possibility, given the meds she's on.

The primary diagnostic differences (or so I understand.....I'm certainly no expert on this stuff so I'm sure others know better than me, @ERDoc @JPINFV, @Nova1300 @medicsb @KellyBracket) between the two are mental status (normal in dystonia; altered with anything from anxiety or agitation to somnolence to coma in SS) and hyperreflexia is present in SS, but not in dystonia. Hyperthermia is also a common finding in SS, though not necessary for diagnosis.

Benadryl will worsen serotonin syndrome (which is potentially fatal), and fentanyl may.


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## STXmedic (Apr 7, 2015)

I wasn't aware that benadryl was so bad for SS. I've got some reading to do. Thanks for the info, Remi.


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## ffemt101986 (Apr 7, 2015)

She was treated for dystonia and given 50mg of diphenhydramine which caused the twitching to subside very quickly and the back pain to calm. When I asked the ER doc what her thoughts were she said it was dystonia caused by the Haldol she had been on for years. I asked if it was a rare side effect and she said it is actually quite common. She said that patients who are on antipsychotics for a long period of time will eventually suffer from some form of dystonia and its hard to tell when or where.


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## chaz90 (Apr 7, 2015)

Nice! Yeah, I think acute dystonia was the gimme here, but good info from everyone on serotonin syndrome. Certainly something to keep in mind and on our list of differentials.


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## LACoGurneyjockey (Apr 7, 2015)

Haldol with muscle spasms pointed me to dystonia pretty early on, with no altered mental status and no fever.
@Remi, with SS will the pupils be dilated like you'd see with meth/ecstasy? What meds on that list led you to suspect serotonin? Hx of bipolar would make me think most decent docs would keep her off SSRI's for the risk of hypermania, but what else are you thinking of there. And how would benadryl or fent worsen it?


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## Carlos Danger (Apr 7, 2015)

LACoGurneyjockey said:


> Haldol with muscle spasms pointed me to dystonia pretty early on, with no altered mental status and no fever.


I agree that simple dystonia was the most likely cause of the presentation described, but given all those meds and the psych history, you have to consider other causes as well, and the presentation described wasn't specific enough to rule out something other than dystonia. Serotonin syndrome is a vague, non-specific presentation that can include dystonic symptoms. 

Based on the presentation described here, I probably would have given Benadryl on scene. But I would have been wary of the fact that it could be something else, and that the Benadryl could potentially make things worse. 



LACoGurneyjockey said:


> what meds on that list led you to suspect serotonin? And how would benadryl or fent worsen it?



Haloperidol, lithium, and ziprasidone all increase serotonin levels, as do many of the drugs that you'd expect to be prescribed a patient like this. The list of drugs that can contribute to serotonin syndrome is long.

Diphenhydramine and fentanyl both reduce uptake of serotonin; Benadryl to a pretty large degree and fentanyl to a smaller degree.

At one of my last clinical sites there was a case of pretty dramatic serotonin syndrome post-operatively. I wasn't there to see it, but supposedly the only drugs they could think of that might have caused it were a couple antidepressants that she'd been on for quite a while with no problems, and the fentanyl that she got in the OR.


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## Brandon O (Apr 8, 2015)

Antipsychotics are NOT usually associated with serotonin syndrome. (I think the typicals have rarely been described as potential causes, but it's not a common reaction.) This may make sense if you reflect that the typical antipsychotics, like haloperidol, largely work by reducing dopamine, whereas the atypicals (like Geodon) mostly reduce, not increase, serotonin. Things like SSRIs and MAOIs are your big culprits.

As far as I know, lithium is also not usually linked with serotonin syndrome, although again, I see there have been some case reports.

In this case, I think dystonia would be at the top of everyone's list, as long as it didn't really look like NMS or seizure.


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## Carlos Danger (Apr 8, 2015)

Brandon O said:


> Antipsychotics are NOT usually associated with serotonin syndrome. (I think the typicals have rarely been described as potential causes, but it's not a common reaction.) This may make sense if you reflect that the typical antipsychotics, like haloperidol, largely work by reducing dopamine, whereas the atypicals (like Geodon) mostly reduce, not increase, serotonin. Things like SSRIs and MAOIs are your big culprits.



The combination of SSRI's and MAOI's is the biggest risk, according to what I've read.

The reason SS jumped out at me as a distinct possibility was more because of the "smorgasbord of medications" that was referenced in the scenario description than the drugs that were listed.

That said, two one of the ones listed are known to increase serotonin levels - I may have been wrong about haloperidol, either by confusing it with droperidol or because all the accounts of the Libby Zion case reference the doses of haldol that she was given before she died from SS:

Drug Induced Serotonin Syndrome
Ziprasidone: "moderate inhibition of serotonin reuptake" as well as direct agonism is 5HT1a receptors
Lithium: "Lithium increases 5-hydroxytryptamine (serotonin) metabolites in the CSF[8] and therefore can interact with SSRIs and cause serotonin syndrome."


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## Brandon O (Apr 8, 2015)

As far as I know, Libby Zion received haloperidol, but it wasn't considered contributory to her death. The pethidine (opiate with a serotoninergic metabolite) and phenelzine (MAOI) were the culprits.

Interesting references. As I alluded to, "anything is possible" in the world of pharm interactions, but there are common things we expect and things we don't. With lithium, for instance, we expect tremors/CNS stuff, GI upset, and kidney stuff (diabetes insipidus is classic).

Serotonin syndrome, hypertensive crisis from MAOI + TCA, "tyramine crisis," and neuroleptic malignant syndrome are a complex of problems that are already similar and hard to keep straight; the fact that different drugs/combinations tend to cause them is one of the only saving graces.


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## ERDoc (Apr 14, 2015)

Late to the party, sorry.  From reading the description I would call it a dystonic reaction and treat with benadryl, but this is one of those scenarios where seeing the pt is worth so much more.  Once you have seen both, you can recognize the difference and it is hard to describe.


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## Kaleb Griffin (Apr 23, 2015)

ffemt101986 said:


> So I don't usually post anything on here but I figured this one was worthy of getting others opinions.
> 
> We were called at about 2200 for a female pt suffering from a seizure. Arrived to find a 49yo female lying in bed with uncontrolled jerking and twitching of her extremities and neck. Pt was CAOx4 and had a complaint of back pain earlier in the evening with severe back and neck pain present at the time of pt contact.  Pt has a history of depression, anxiety, Bipolar and suicidal attempts and a smorgasbord of medications to go along with it. The big ones being Haldol, lithium and Geodon.  Her husband stated there was no way she could have overdosed on any medication because they are locked up and he has had the only key on him all evening. Pt has a B/P of 156/92, Pulse of 116 strong and regular showing sinus tach on the monitor with quite a bit of artifact due to the jerking. Blood sugar of 156 and resp rate of 26 and labored and an O2 sat of 98% on room air. Im going to open myself up for criticism and admit to going all "Ambulance Driver" on this one. I did some research and think ive got it figured out and am kicking myself the *** now, but I want some other opinions.


Did her eyes look like they were going back into her head (oculogyric crisis)?  The dystonia might have been in the early stages before it could lead to that though. That is one type of dystonia that I haven't seen yet in my mental health clinical rotation in nursing school.  Interesting scenario!


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