Dystonia presentation

bizzy522

bizzy522

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Just got a call for a unresponsive subject. On arrival we found a male in his twenties sitting upright on a bench with his back arched, chin tilted upward, staring strait ahead. Unresponsive to verbal and only made incomprehensible sounds on painful stimulus. Airway patent , breathing extremely slow and DEEP , skin was WPD with a palpable pulse. Blood glucose was within normal limits, BP 102/68, RR deep 4-6/min, HR sinus tach @ 150.. Otherwise 12 lead unremarkable, spo2 99 on RA, ETCO2 35. Patient eyes PERRL, no signs of injury or trauma. Patient's mental status was untouched by 2 mg of narcan, or 50 mg of diphenhydramine. Ventilations were assisted to the receiving ED (5 minutes away).
How many of you have had experiences with dystonic patients, what were your findings? ( General appearance, vital signs, reaction to diphenhydramine.) One of my coworkers also thought that it could be Spice but I've never seen k2 present that way?
Thoughts?
 
I know K2 can present in a bunch of different ways.
 
In my experience I've seen spice have dramatically different effects on people... Including the kind of presentation you described. I've had like 2 or 3 good interesting ones where everyone on scene was hee-hawing about what it could be, and I deferred to the benedryl which had a positive full or partial reversal.

They say it's "rare," but I feel like I've seen more than my fair share.
 
I've only had one potential patient present with dystonic symptoms, muscle contractions, inability to speak, with recent accidental neuroleptic overdose. Tried Benadryl 50 mg IV w/o success but Ativan 2 mg seemed to take away most of the symptoms.
 
Could be many things -- drugs, absence seizure, chronic condition. The tachycardia among the other vitals is interesting. Fever? History?
 
mgr22 said:
Could be many things -- drugs, absence seizure, chronic condition. The tachycardia among the other vitals is interesting. Fever? History?
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Only history known was drug abuse (methamphetamines) . No fever noted.
 
Can be caused by a lot of things. Why did you assist ventilation to hospital? RR of 4-6 a minute is fine, if pt is perfusing fine.
 
I have never heard of Benadryl for this before. What is the action of it in this case? I would assume the anticholinergic property. Does this typically resolve the dystonic symptoms completely?
 
Always keep in mind that someone like this could be a polypharmcy ingestion. No one likes to read the textbook and overdose on one drug. Other things to think of are serotonin symdrome and NMS. In the field (and in the ealry stages of the ER stay) treatment is pretty much a crap shoot.
 
We were talking about this in class and the diphenhydramine will usually only work if the dystonic reaction is caused by a medication (usually an anti-psychotic). Some patients are born with or develop dystonic reactions. I know you say that you only have a drug use hx, was that from a family member? If it's hereditary it usually shows up in childhood, but it might be possible to have a later onset.
 
ERDoc said:
Always keep in mind that someone like this could be a polypharmcy ingestion. No one likes to read the textbook and overdose on one drug. Other things to think of are serotonin symdrome and NMS. In the field (and in the ealry stages of the ER stay) treatment is pretty much a crap shoot.
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Yeah, the myoclonus is a good clue, I see dystonia as more of a tremor or fasciculation; shame there's no temp included.
 
BlueJayMedic said:
I have never heard of Benadryl for this before. What is the action of it in this case? I would assume the anticholinergic property. Does this typically resolve the dystonic symptoms completely?
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Benadryl is thought to work because it stabilizes the central dopamine receptors; which are also thought to impact muscle coordination/fine motor. As an example, Parkinson patients are given dopaminergic medications to achieve the same thing.

I suppose the degree that it resolves the issue is tied with the substance, the scale of dopamine receptors involved, and the respective half lives of each.
 
Doesn't sound like dystonic reaction. Those usually they are fully alert. They usually try to speak and can't move their tongues/mouths. Many times they know what it is and have experienced it before with their psych meds. They respond and follow commands.

This sounds like drugs/etoh or psych from what you wrote
 
What exactly was it that made you give Benadryl?

I've certainly seen k2 present like that.
 
What is "K2"? Do you guys see a lot of Spice? I have never seen it before; never even heard anyone I work with mention seeing it.
On the other hand, we do see a lot of GHB. I had never seen GHB in the area I worked previously. It seems that a lot of these exotic drugs are regional.
What part of the country do you guys work in?
 
zzyzx said:
What is "K2"? Do you guys see a lot of Spice? I have never seen it before; never even heard anyone I work with mention seeing it.
On the other hand, we do see a lot of GHB. I had never seen GHB in the area I worked previously. It seems that a lot of these exotic drugs are regional.
What part of the country do you guys work in?
Click to expand...


K2 is another name for spice. The thing about spice is that since it's synthetic and there's obviously no regulation, the reactions and doses vary a lot depending on who made it. I've worked in several places in southern CA and I've seen it a handful of times. I've never seen anyone have a reaction like this, most of the reactions I've seen have been paranoid and hallucinating. One guy thought he was smoking weed- it was his first time doing any drug. He thought we were there to rip his skin off, we ended up needing to restrain him.

Maybe there is a regional component- I've never seen GHB out here. I've heard of it being used recreationally, but I haven't run any calls for it.
 
I had a call for spice a few years back when it first got popular.
I googled it on the way to the call to find out what the hell it was. Kid took one hit of it and had a seizure.
 
My experience with K2 is usually the patient being some degree of decreased mentation up to being comatose, hypotensive, and tachycardic. Seizures, combative, etc. have been seen. When I know it's K2 (package on pt., or bystander confirming K2 use), I'll take a semi-conservative approach - fluids, labs, UDS, CT head, ECG, CXR, and close monitoring until it wears off then DC to home. If I don't have a good story and their mentation is depressed enough, they get intubated in addition to the work up. The ICU has seen enough that they often end up exubating them when they wake and then DC to home if everything else is normal. Frequently a <24 hour ICU stay. Unfortunately there is not test for K2 or synthetic marijuana and the presentation varies a lot. Many have been made traumas due to signs of injury. They often get intubated and end up having a negative work up. In many cases, they wake in a few hours and then extubated and sent home from the ED without ever getting to the ICU.

At least w/ PCP, you can test for it and they have physical exam findings (nystagmus and the characteristic smell on their breath), saving the expensive work up beyond a CT head and an accucheck. They sleep it off and then get sent home.
 
Sometimes in the ED I used to work in a patient would have a dystonic reaction (per the doctors who told us that what is was, but the symptoms are what are being described here) to getting Benadryl IV pushed too fast: we had nurses that slammed everything. and the treatment was Benadryl IV pushed over about 5 minutes.
 
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