How to diagnose Neuroleptic Malignant Syndrome (NMS) in a patient who has experienced a fall with prolonged immobilization?

From the Guidelines

Diagnosing neuroleptic malignant syndrome (NMS) in a patient who has also experienced a fall with prolonged immobility requires careful clinical assessment to distinguish between these potentially overlapping conditions, with a focus on identifying the cardinal features of NMS, including hyperthermia, muscle rigidity, altered mental status, and autonomic instability, as outlined in the study by 1. To diagnose NMS, begin by evaluating for these cardinal features, which are the hallmarks of the condition, as noted in the study by 1. Laboratory tests should include creatine kinase (CK) levels, which are typically markedly elevated in NMS, complete blood count, comprehensive metabolic panel, and urinalysis to assess for myoglobinuria. Some key points to consider in the diagnosis of NMS include:

• Hyperthermia, often greater than 38°C, which is a key feature of NMS, as noted in the study by 1
• Muscle rigidity, which can manifest as lead pipe rigidity, akinesia, dyskinesia, or waxy flexibility, as described in the study by 1
• Altered mental status, which can range from delirium to agitation to stupor to coma, as outlined in the study by 1
• Autonomic instability, which can include tachycardia, blood pressure fluctuations, diaphoresis, and other symptoms, as noted in the study by 1 The temporal relationship between antipsychotic exposure and symptom onset is crucial, as NMS typically develops within 1-4 weeks of starting or increasing the dose, as noted in the study by 1. Differential diagnosis should include rhabdomyolysis from prolonged immobility after a fall, serotonin syndrome, malignant hyperthermia, and infection, as outlined in the study by 1. Management of NMS involves immediate discontinuation of the suspected causative agent, supportive care, and possibly specific treatments like dantrolene or bromocriptine, as recommended in the study by 1. Some key points to consider in the management of NMS include:
• Immediate discontinuation of the antipsychotic medication, as recommended in the study by 1
• Supportive care, including cardiorespiratory support and management of dehydration and electrolyte imbalances, as outlined in the study by 1
• Specific treatments, such as dantrolene or bromocriptine, which may be used to manage severe rigidity or dopamine receptor antagonism, as recommended in the study by 1

From the Research

Diagnosing NMS in Someone Who Has Had a Fall with Long Lie

To diagnose Neuroleptic Malignant Syndrome (NMS) in someone who has also had a fall with long lie, consider the following:

• The patient's medical history and symptomatology are crucial in diagnosing NMS 2
• Typical clinical picture of NMS consists of altered consciousness, muscular rigidity, fever, and autonomic instability 3
• Presentation of NMS can vary, and diagnosis relies primarily upon medical history and symptomatology 2
• Emergency physicians should remain vigilant in recognizing the symptoms of NMS and be prepared to initiate immediate treatment following diagnosis 2

Key Symptoms to Look Out For

• Hyperthermia
• Rigidity
• Autonomic disturbances
• Altered consciousness 4
• Muscular rigidity
• Fever
• Autonomic instability 3

Importance of Timely Diagnosis

• Timely diagnosis and discontinuation of antipsychotic therapy is the first-line treatment for NMS 5
• Delay in diagnosis can lead to potentially fatal complications 4, 2
• Emergency physicians should be prepared to initiate immediate treatment following diagnosis 2