Managing Acute Dystonic Reactions – A Critical UKMLA/PLAB Scenario
Master Emergency Clinical Scenarios for UKMLA and PLAB Success
This article explores a critical question from the August 2024 PLAB 1 exam, focusing on the recognition and immediate management of acute dystonic reactions. These potentially alarming side effects, often associated with dopamine receptor antagonists like metoclopramide, test your ability to provide rapid and effective treatment in high-pressure scenarios.
PLAB 1 Exam Case Scenario: A 45-year-old man develops acute-onset neck stiffness, difficulty swallowing, and a swollen tongue shortly after receiving intravenous metoclopramide for postoperative nausea. He is unable to move his neck normally and appears distressed.
Which is the most appropriate immediate management?
A) Administer intravenous diazepam
B) Commence intravenous hydrocortisone
C) Prescribe oral prochlorperazine
D) Stop metoclopramide and administer intramuscular procyclidine
E) Switch to ondansetron for nausea control
Answer with an explanation is provided below.
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Correct Answer: D) Stop Metoclopramide and Administer Intramuscular Procyclidine
Explanation and Clinical Reasoning
Key Features of Acute Dystonic Reactions
Rapid Onset:
Symptoms typically appear within hours of administering dopamine receptor antagonists such as metoclopramide.
Muscle Spasms:
Involuntary and often painful contractions, particularly in the neck (torticollis), jaw (trismus), or eyes (oculogyric crisis).
Dysphagia and Distress:
Difficulty swallowing due to pharyngeal muscle involvement, along with distress from the inability to control movements.
Reversible with Prompt Treatment:
Rapid administration of anticholinergic agents can reverse symptoms within minutes to an hour.
Why Procyclidine is the Optimal Treatment
Mechanism of Action:
Procyclidine, an anticholinergic, counters the dopamine blockade caused by metoclopramide. By restoring the balance between acetylcholine and dopamine in the basal ganglia, it alleviates dystonic symptoms.Fast Relief:
Intramuscular or intravenous procyclidine provides rapid symptom relief, making it the first-line treatment for acute dystonic reactions.Stopping Metoclopramide:
Discontinuing the offending agent prevents further exacerbation of symptoms.
Why Other Options Are Less Appropriate
A) Administer Intravenous Diazepam:
Diazepam may provide muscle relaxation but does not address the underlying dopamine-acetylcholine imbalance causing the dystonia.
B) Commence Intravenous Hydrocortisone:
Steroids are ineffective in treating acute dystonic reactions and do not address the pathophysiology.
C) Prescribe Oral Prochlorperazine:
Prochlorperazine, another dopamine receptor antagonist, could worsen the dystonia and is contraindicated.
E) Switch to Ondansetron for Nausea Control:
While ondansetron is a safer antiemetic alternative, it does not treat the acute dystonic reaction. The immediate priority is symptom reversal with procyclidine.
Management and Follow-Up
Immediate Steps:
Administer Procyclidine:
Administer intramuscular or intravenous procyclidine promptly. Alternative options, such as benztropine or diphenhydramine, can be used if procyclidine is unavailable.
Discontinue Metoclopramide:
Stop metoclopramide immediately to prevent symptom progression.
Monitor the Patient:
Observe for improvement in symptoms and any complications, such as respiratory distress.
Long-Term Considerations:
Switch to Safer Antiemetics:
Consider ondansetron for future nausea control to avoid dopamine antagonists.
Patient Education:
Inform the patient about their reaction and the need to avoid medications like metoclopramide in the future.
Prevention:
Document the adverse reaction in the patient’s medical records to prevent re-exposure.
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Reference:
NICE Guidelines: Guidance on the management of drug-induced movement disorders, including acute dystonia.
Patient.info: Insights into recognising and managing dystonic reactions.
Remember: This blog post is for educational purposes only and should not be considered medical advice.
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