Neuroleptic malignant syndrome - Revision history

Danbot: Strip excess bold

2026-03-22T09:30:48Z

Strip excess bold

Danbot: Major update: NMS vs SS comparison table, iron level evaluation, avoid succinylcholine, bromocriptine duration, rechallenge guidance, depot antipsychotic timeline, added references with PMIDs

2026-03-21T19:41:09Z

Major update: NMS vs SS comparison table, iron level evaluation, avoid succinylcholine, bromocriptine duration, rechallenge guidance, depot antipsychotic timeline, added references with PMIDs

Show changes

Danbot: Add MedicationDose SMW annotations (4 entries: lorazepam, dantrolene, bromocriptine, amantadine); dosing verified

2026-03-20T16:32:59Z

Add MedicationDose SMW annotations (4 entries: lorazepam, dantrolene, bromocriptine, amantadine); dosing verified

← Revisión anterior		Revisión del 16:32 20 mar 2026
Línea 94:		Línea 94:
	*Admit, usually to ICU		*Admit, usually to ICU


			<div style="display:none">
			<!-- SMW MedicationDose annotations for NMS medications -->
			{{MedicationDose\|drug=Lorazepam\|dose=2 mg IV q5min until agitation and rigidity resolve\|route=IV\|context=Benzodiazepine for agitation/rigidity\|indication=Neuroleptic malignant syndrome}}
			{{MedicationDose\|drug=Dantrolene\|dose=0.25-2 mg/kg IV q6-12h\|route=IV\|context=Skeletal muscle relaxant (severe rigidity only)\|indication=Neuroleptic malignant syndrome\|max_dose=10 mg/kg/day\|notes=Controversial efficacy; may cause hepatotoxicity in liver disease}}
			{{MedicationDose\|drug=Bromocriptine\|dose=2.5 mg PO q6-8h\|route=PO\|context=Dopamine agonist\|indication=Neuroleptic malignant syndrome\|max_dose=40 mg/day\|notes=Controversial efficacy}}
			{{MedicationDose\|drug=Amantadine\|dose=100 mg PO initially, titrate up to max 200 mg q12h\|route=PO\|context=Alternative dopamine agonist\|indication=Neuroleptic malignant syndrome\|max_dose=200 mg q12h}}
			</div>
	==See Also==		==See Also==

Rossdonaldson1: /* Clinical Features */

2022-09-21T22:44:00Z

Clinical Features

← Revisión anterior		Revisión del 22:44 21 sep 2022
Línea 11:		Línea 11:

	==Clinical Features==		==Clinical Features==
			[[File:PMC3703349 CRIM.DENTISTRY2013-542130.002.png\|thumb\|Patient exhibiting NMS symptoms: hyperthermia, significant extrapyramidal symptoms, various autonomic symptoms, and impaired consciousness.]]
	*Develops over 1-3 days		*Develops over 1-3 days
	*Tetrad of:<ref>Gurrera RJ, Velamoor V, Cernovsky ZZ. A Validation Study of the International Consensus Diagnostic Criteria for Neuroleptic Malignant Syndrome. J Clin Psychopharmacol. Aug 22 2013</ref>		*Tetrad of:<ref>Gurrera RJ, Velamoor V, Cernovsky ZZ. A Validation Study of the International Consensus Diagnostic Criteria for Neuroleptic Malignant Syndrome. J Clin Psychopharmacol. Aug 22 2013</ref>

Elcatracho: /* Disposition */

2021-03-03T16:44:18Z

Disposition

← Revisión anterior		Revisión del 16:44 3 mar 2021
Línea 92:		Línea 92:
	==Disposition==		==Disposition==
	*Admit, usually to ICU		*Admit, usually to ICU


	==See Also==		==See Also==

Elcatracho: /* Differential Diagnosis */

2021-01-01T05:41:48Z

Differential Diagnosis

← Revisión anterior		Revisión del 05:41 1 ene 2021
Línea 34:		Línea 34:
	*[[Serotonin Syndrome]]		*[[Serotonin Syndrome]]
	**Serotonin syndrome more likely to have hyperreflexia, myoclonus, ataxia, nausea and vomiting, diarrhea		**Serotonin syndrome more likely to have hyperreflexia, myoclonus, ataxia, nausea and vomiting, diarrhea
	**Rigidity and hyperthermia, if present, is less severe than in NMS		**Rigidity and hyperthermia, if present, is less severe than in NMS; more commonly presents with clonus and hyperreflexia
	*[[Malignant Hyperthermia]]		*[[Malignant Hyperthermia]]
	**Distinguish by clinical setting (use of inhalational anesthetics or sux)		**Distinguish by clinical setting (use of inhalational anesthetics or sux)

Rossdonaldson1: /* Differential Diagnosis */

2020-11-14T13:43:40Z

Differential Diagnosis

← Revisión anterior		Revisión del 13:43 14 nov 2020
Línea 43:		Línea 43:
	*[[Sympathomimetics]]		*[[Sympathomimetics]]
	**Rigidity is not seen		**Rigidity is not seen

	{{Movement disorder DDX}}		{{Movement disorder DDX}}
	{{AMS and fever DDX}}		{{AMS and fever DDX}}

Rossdonaldson1: /* Differential Diagnosis */

2020-11-14T13:40:44Z

Differential Diagnosis

← Revisión anterior		Revisión del 13:40 14 nov 2020
Línea 43:		Línea 43:
	*[[Sympathomimetics]]		*[[Sympathomimetics]]
	**Rigidity is not seen		**Rigidity is not seen
			{{Movement disorder DDX}}
	{{AMS and fever DDX}}		{{AMS and fever DDX}}

Shihabali: /* Management */

2019-11-22T06:26:07Z

Management

← Revisión anterior		Revisión del 06:26 22 nov 2019
Línea 65:		Línea 65:
	==Management==		==Management==
	*The causative agent should be stopped		*The causative agent should be stopped
			*Discontinue all dopamine blocking agents
	*If precipitant is a dopaminergic therapy (L-dopa or Carbidopa) it can be restarted later at lower doses as an outpatient		*If precipitant is a dopaminergic therapy (L-dopa or Carbidopa) it can be restarted later at lower doses as an outpatient

	===Supportive Care===		===Supportive Care===
	*Agitation should be controlled with [[Benzodiazepines]]		*Agitation should be controlled with [[Benzodiazepines]]
			**Lorazepam 2 mg IV q5 min until agitation and muscle rigidity resolves
	*[[Fluid resuscitation]]		*[[Fluid resuscitation]]
	*Cooling measures		*Cooling measures
	*Intubation and paralysis for severe cases, chest wall rigidity or respiratory failure		*Intubation and paralysis for severe cases, chest wall rigidity or respiratory failure
			**Use NON-DEPOLARIZING paralytic agent

	===Directed Medical Therapy<ref>Addonizio G, Susman VL, Roth SD. Neuroleptic malignant syndrome: review and analysis of 115 cases. Biol Psychiatry. Aug 1987;22(8):1004-20 </ref>===		===Directed Medical Therapy<ref>Addonizio G, Susman VL, Roth SD. Neuroleptic malignant syndrome: review and analysis of 115 cases. Biol Psychiatry. Aug 1987;22(8):1004-20 </ref>===
Línea 82:		Línea 85:
	*[[Amantadine]] (alternative to bromocriptine)		*[[Amantadine]] (alternative to bromocriptine)
	**100mg PO initially; titrate up as needed to max dose 200mg q12hr		**100mg PO initially; titrate up as needed to max dose 200mg q12hr

			===Electroconvulsive Therapy===
			*Limited case series suggest that ECT can be effective in NMS refractory to pharmacotherapy<ref>Morcos N et al., Electroconvulsive therapy for neuroleptic malignant syndrome: a case series. J ECT. 2019.</ref>

	==Disposition==		==Disposition==

ClaireLewis at 14:48, 11 October 2019

2019-10-11T14:48:46Z

← Revisión anterior		Revisión del 14:48 11 oct 2019
Línea 11:		Línea 11:

	==Clinical Features==		==Clinical Features==
			*Develops over 1-3 days
	*Tetrad of:<ref>Gurrera RJ, Velamoor V, Cernovsky ZZ. A Validation Study of the International Consensus Diagnostic Criteria for Neuroleptic Malignant Syndrome. J Clin Psychopharmacol. Aug 22 2013</ref>		*Tetrad of:<ref>Gurrera RJ, Velamoor V, Cernovsky ZZ. A Validation Study of the International Consensus Diagnostic Criteria for Neuroleptic Malignant Syndrome. J Clin Psychopharmacol. Aug 22 2013</ref>
	**[[Altered mental status]] - ~~Agitated~~ delirium progressing to stupor/coma		**[[Altered mental status]] - [[agitated delirium]] progressing to stupor/[[coma]]
	**~~Muscular Rigidity~~ - ~~Generalized~~, "lead pipe" rigidity		**Muscle rigidity - generalized, "lead pipe" rigidity
	**[[Hyperthermia]] >38C (87%); >40C (40%)		**[[Hyperthermia]] >38C (87%); >40C (40%)
	**Autonomic ~~Instability~~ - ~~Tachycardia~~, ~~Hypertension~~, ~~Diaphoresis~~		**Autonomic instability - [[tachycardia]], [[hypertension]], diaphoresis

			===Complications===
			*[[Dehydration]]
			*[[Electrolyte imbalance]]
			*[[Acute renal failure]] ([[rhabdomyolysis]])
			*[[Dysrhythmias ]]
			*[[ACS]]
			*[[Respiratory failure]]
			**Chest wall rigidity, aspiration [[pneumonia]], [[PE]]
			*[[DIC]]
			*[[Seizure]] ([[hyperthermia]], [[electrolyte derangements]])
			*[[Hepatic failure]]
			*[[Sepsis]]

	==Differential Diagnosis==		==Differential Diagnosis==
	*[[Serotonin Syndrome]]		*[[Serotonin Syndrome]]
	**~~More~~ likely to have hyperreflexia, myoclonus, ~~ataxis~~, nausea and vomiting, diarrhea		**Serotonin syndrome more likely to have hyperreflexia, myoclonus, ataxia, nausea and vomiting, diarrhea
	**Rigidity and hyperthermia, if present, is less severe than in NMS		**Rigidity and hyperthermia, if present, is less severe than in NMS
	*[[Malignant Hyperthermia]]		*[[Malignant Hyperthermia]]
Línea 33:		Línea 47:

	==Evaluation==		==Evaluation==
	~~===Workup===~~
	*Total CK		*Total CK
	**Typically >1000		**Typically >1000
	**Correlates with degree of rigidity		**Correlates with degree of rigidity
	*CBC		*CBC
	**WBC >10K is typical		**[[leukocytosis\|WBC >10K]] is typical
	*Chemistry		*Chemistry
	**May show hypocalcemia, hypomagnesemia, hyperkalemia, metabolic acidosis		**May show [[hypocalcemia]], [[hypomagnesemia]], [[hyperkalemia]], [[metabolic acidosis]]
	*[[Urinalysis]]		*[[Urinalysis]]
	**Myoglobinuria (from rhabdo)		**Myoglobinuria (from rhabdo)
	*~~LFT~~		*[[LFTs]]
	**Transaminitis		**Transaminitis
	*CT/[[LP]]		*[[head CT\|CT]]/[[LP]]
	**CSF may have mildly elevated protein		**CSF may have mildly elevated protein

Línea 73:		Línea 86:
	*Admit, usually to ICU		*Admit, usually to ICU

	~~==Complications==~~
	*Dehydration
	*[[Electrolyte imbalance]]
	*[[Acute renal failure]] ([[rhabdomyolysis]])
	*[[Dysrhythmias ]]
	*[[ACS]]
	*[[Respiratory failure]]
	**Chest wall rigidity, aspiration [[pneumonia]], [[PE]]
	*[[DIC]]
	*[[Seizure]] ([[hyperthermia]], [[electrolyte derangements]])
	*[[Hepatic failure]]
	*[[Sepsis]]

	==See Also==		==See Also==