What is the plan from a Consultation-Liaison (CL) psychiatry perspective for a patient with suspected Neuroleptic Malignant Syndrome (NMS) following a fall with prolonged immobilization, with differential diagnoses including sepsis and hyperactive delirium?

From the Guidelines

For a patient with suspected Neuroleptic Malignant Syndrome (NMS) following a fall with prolonged immobility, while considering sepsis and hyperactive delirium as differential diagnoses, I recommend immediate discontinuation of all antipsychotic medications and implementation of supportive care. The patient should be transferred to an intensive care unit for close monitoring of vital signs, fluid status, and electrolyte balance. Intravenous hydration should be initiated promptly to prevent renal failure from rhabdomyolysis, as suggested by 1. Specific pharmacological interventions include benzodiazepines such as lorazepam (1-2 mg IV every 4-6 hours) to help manage agitation while avoiding antipsychotics, as recommended by experts 1.

Key Considerations

• Laboratory monitoring should include CPK levels, renal function tests, complete blood count, and cultures to differentiate NMS from sepsis, considering the broad differential diagnosis outlined in 1.
• Cooling measures should be implemented for hyperthermia, and for hyperactive delirium management without antipsychotics, consider alpha-2 agonists like dexmedetomidine or clonidine if benzodiazepines are insufficient.
• The diagnosis of NMS is clinical, relying on a history of antipsychotic use or withdrawal of a dopaminergic agent, along with symptoms such as hyperthermia, rigidity, and mental status alteration, as discussed in 1.

Management Approach

• The treatment approach should address the pathophysiology of NMS, which involves dopamine receptor blockade leading to dysregulation of the autonomic nervous system and hyperthermia, while simultaneously managing potential sepsis and delirium until definitive diagnosis is established.
• Supportive care, as outlined in 1, including management of cardiorespiratory compromise with standard supportive measures, treatment of dehydration or elevated creatine kinase with IV fluids, and consideration of hemodialysis if renal failure occurs, is crucial.
• Benzodiazepines are recommended as the first-line agent for agitation 1, emphasizing the importance of managing symptoms while avoiding antipsychotics that could exacerbate NMS.

From the FDA Drug Label

Neuroleptic Malignant Syndrome (NMS) A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with antipsychotic drugs Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status (including catatonic signs) and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmias). The management of NMS should include 1) immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy, 2) intensive symptomatic treatment and medical monitoring, and 3) treatment of any concomitant serious medical problems for which specific treatments are available

From a CL psychiatry perspective, the plan for a patient with suspected Neuroleptic Malignant Syndrome (NMS) following a fall with long lie, with other differentials including sepsis and hyperactive delirium, would be to:

• Immediately discontinue any antipsychotic medications and other non-essential drugs
• Provide intensive symptomatic treatment and close medical monitoring
• Treat any concomitant serious medical problems, such as sepsis, with specific treatments available
• Consider alternative explanations for the patient's symptoms, including hyperactive delirium and sepsis, and investigate these further as needed
• Carefully monitor the patient for signs of NMS, as well as for other potential complications, and adjust the treatment plan accordingly 2, 2, 2

From the Research

Diagnosis and Treatment Plan

To approach a patient with suspected Neuroleptic Malignant Syndrome (NMS) following a fall with long lie, and other differentials including sepsis and hyperactive delirium, the following steps should be considered:

• Immediately stop any dopamine-receptor antagonists, as these can exacerbate NMS 3, 4, 5
• Implement supportive measures such as hydration, temperature control, and monitoring of vital signs 3, 6, 5
• Consider pharmacological interventions such as bromocriptine, dantrolene, benzodiazepines, and/or electroconvulsive therapy in more severe cases 3, 7, 5

Differential Diagnosis

When considering the diagnosis of NMS, it is essential to rule out other potential causes of the patient's symptoms, including:

• Sepsis: characterized by fever, altered mental status, and autonomic dysfunction, which can be similar to NMS 3, 4
• Hyperactive delirium: characterized by agitation, altered mental status, and autonomic dysfunction, which can be similar to NMS 6, 5
• Other malignant catatonic syndromes: such as malignant catatonia, which can have similar symptoms to NMS 3, 6

Risk Stratification

Patients at high risk for NMS, such as those with a history of dopamine withdrawal or those taking neuroleptic medications, should be closely monitored for signs and symptoms of NMS 4, 6

• Consider avoiding neuroleptic medications in patients at highest risk for NMS, particularly those who are withdrawing from dopaminergic agents 4

Monitoring and Management

Patients with suspected NMS should be closely monitored for signs and symptoms of the disorder, including:

• Fever
• Muscle rigidity
• Altered mental status
• Autonomic dysfunction
• Rhabdomyolysis
• Acute kidney failure 3, 6, 5
• Consider consultation with a psychiatrist or neurologist for further evaluation and management 3, 6, 5