Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Stop offending/replace dopaminergic therapy; ICU supportive care and cooling.
- Treat rigidity with dantrolene; add bromocriptine/amantadine as needed.
- Monitor CK/renal function; gradual reintroduction of antipsychotic only after full recovery.
Clinical Synopsis & Reasoning
Idiosyncratic reaction to dopamine antagonists or withdrawal of dopaminergic drugs. Presents with hyperthermia, rigidity, autonomic instability, and elevated CK. Stop offending agents, provide aggressive supportive care, and consider dantrolene, bromocriptine, or amantadine in moderate–severe cases.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Medication/exposure review | Etiology | D2 antagonist exposure or dopamine withdrawal | Critical clue |
| CK, BMP, LFTs, UA/myoglobin | Complications | Rhabdomyolysis, AKI | Trend CK |
| Infectious/serotonergic workup as needed | Differential | Distinguish from SS, MH | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Hyperthermia, rigidity, autonomic instability | Life-threatening | ICU; stop dopamine blockers; aggressive support |
| CK >1000–5000 with rising creatinine | Rhabdomyolysis/AKI | High-volume fluids; treat hyperkalemia |
| Altered mental status with airway risk | Aspiration/resp failure | Intubate; sedation |
| Recent dopamine withdrawal (Parkinson’s) | Akinetic crisis | Restart dopaminergic therapy |
| No improvement within 24–48 h | Refractory | Consider dantrolene/bromocriptine/amantadine |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Stop dopamine antagonists; restart/augment dopaminergic therapy if withdrawal | Cause reversal | Immediate | Key intervention | — |
| Dantrolene 1–2.5 mg/kg IV q6h (selected) | Muscle relaxant | Hours | Severe rigidity/hyperthermia | Monitor LFTs |
| Bromocriptine 2.5–10 mg PO/NG q6–8 h (or Amantadine) | Dopamine agonist | Hours | Adjunct therapy | — |
| Aggressive fluids/electrolytes; cooling; ICU monitoring | Supportive | Immediate | Prevent complications | — |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- NMS management reviews and neuroemergency statements — Link