Sunday, January 20, 2013

Dystonia - not a polish travel destination!


A recent case posted on an EMS related Facebook page asked providers if they can and would treat dystonic reactions in the field. Dystonia is a reversible extrapyramidal effect that can occur after administration of certain drugs, characterized by sustained involuntary contractions of muscles throughout the body. It is not a polish destination spot! With treatment, these symptoms can be alleviated quickly and safely - even in the prehospital setting.  So the answer to the question is: yes, a prehospital provider should treat dystonic reactions in the field!

 However, I understand that many providers may not be familiar with this condition and how to treat it.  I am not certain if dystonia is listed in the teaching objectives of initial EMS classes, and therefore, continuous education may need to focus on more abstract conditions like dystonia and other disorders, especially if they are a potential side effect of medications we give in the field. As an example, dystonic reactions can be induced by a potent dopamine D2 receptor antagonist like haloperidol, and even by commonly given antiemetic medications like promethazine. A quick search on Medscape showed that “although dystonic reactions are occasionally dose related these reactions are more often idiosyncratic and unpredictable.” They reportedly arise from a drug-induced dopaminergic-cholinergic imbalance “which leads to an excess of striatal cholinergic output.”

 The treatment is simple, and well within the scope of EMS providers – although medical control contact may be required for orders since this is not commonly mentioned in protocols. If you encounter a suspected dystonic reaction, IV administration of diphenhydramine 25-50 mg is repeatedly recommended by literature. The reason is that diphenhydramine, although an antihistamine also possesses significant anticholinergic properties. These properties may help by blocking striatal cholinergic receptors, therefore rebalancing cholinergic and dopaminergic activity.

 How about that!!!
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5 comments:

  1. J.A.M.B - erJanuary 20, 2013 at 10:49 AM

    I feel that this is some additional relevant information for providers that was listed on Medscape:
    "The diagnosis is usually apparent from the history and physical examination. A history of medication exposure is usually obtained. Even when a supporting history is not obtained, the clinical picture alone is enough to strongly suggest the diagnosis. A predictable, rapid resolution of symptoms following treatment confirms the diagnosis. Failure to improve, however, should prompt the clinician to consider alternative diagnosis."

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  2. Vince DJanuary 21, 2013 at 9:33 PM

    I've never encountered this condition in the field but it's definitely one of my favorite presentations to see treated in the ED. Patient comes in, sometimes with a fairly dramatic presentation visually, and with a simple push of some diphenhydramine their symptoms resolve almost in front of you. These are the kind of see, treat, and street patients that we live for in EM.

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    Replies
    1. UnknownJanuary 22, 2013 at 12:37 AM

      I had the reaction to Levaquin and it took a few hours to get bad. I recieved a combo of 50mg Dyphenhydramine IM and 1mg Ativan PO. It is recommended however to give both meds IV if possible for the effect to be quicker. Vince, I have had it multiple times and have had the combo I listed both IV and IM and PO and IV is the quickest at treating it. The reaction is rather scary from a patients perspective so in addition to the medical side you should always treat the psychological side of the patient as well.

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    2. J.A.M.B - erJanuary 22, 2013 at 3:39 PM

      Thanks for your comments and feedback! This is an interesting condition from a medical standpoint and an easy to treat and help a patient from a humanitarian standpoint. I like the additional administration of Ativan. Will any benzo work? Does Ativan have an extra property to help dystonia over other medications like Valium or Versed?

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    3. Vince DJanuary 25, 2013 at 12:28 AM

      Thanks for the feedback Adam - at our shop every case I've seen has been treated with IV diphenhydramine.

      JAMB - from my understanding the main role of benzos is for anxiolysis and reduction of muscle spasm, so any of the big three will probably do. Looking at things from an EM standpoint, if I'm going IV I might favor midazolam because it has a quicker on/off than the others.


      Here's one of my favorite video cases showing the presentation of an acute dystonic reaction, it's rapid treatment, and also the euphoric effects we sometimes see when using the IV route (probably exacerbated by the patient's baseline schizophrenia).

      https://www.youtube.com/watch?v=_pPpWZcjwNg

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