Acute Dystonia & Extrapyramidal Symptoms (EPS) Management

Algorithm Steps

1. ▶

   Start

   Suspected EPS/Acute Dystonia

   Patient on dopamine-blocking agent with movement disorder

   1. ◆

      Decision

      Identify Type of EPS

      Different syndromes require different management

      1. ⚠

         Warning

         ⚠️ ACUTE DYSTONIA

         Sustained muscle contractions - EMERGENCY

         • Onset: Within 48-72 hours of starting/increasing dose
         • 90% occur within first 5 days
         • Torticollis (neck twisting)
         • Oculogyric crisis (eyes rolled back)
         • Trismus (jaw clenching)
         • Laryngeal dystonia (stridor - AIRWAY EMERGENCY)
         • Opisthotonos (arched back)
         1. ●

            Action

            Immediate Treatment

            Anticholinergic reversal

            • BENZTROPINE 1-2mg IM or IV
            • - Onset: 5-15 minutes
            • - Can repeat in 30 min if needed
            • OR DIPHENHYDRAMINE 25-50mg IM or IV
            • - Alternative if benztropine unavailable
            • Relief usually within minutes
            • ⚠️ If laryngeal dystonia: Secure airway first!
            1. ●

               Action

               Prophylaxis After Dystonia

               Prevent recurrence

               • Continue oral anticholinergic 48-72 hours
               • Benztropine 1-2mg BID or
               • Trihexyphenidyl 2mg BID
               • Consider prophylaxis when starting high-potency AP
               • Risk factors: young, male, high-potency FGA
               1. ◆

                  Decision

                  Need to Continue Antipsychotic?

                  Evaluate ongoing need

                  1. ●

                     Action

                     Consider Switching Antipsychotic

                     Lower EPS risk options

                     • Quetiapine (low EPS risk)
                     • Clozapine (lowest EPS risk)
                     • Aripiprazole (partial agonist)
                     • Avoid high-potency FGAs if EPS history
                     1. ●

                        Action

                        Ongoing Monitoring

                        Use standardized scales

                        • AIMS (Abnormal Involuntary Movement Scale) q3-6mo
                        • Barnes Akathisia Rating Scale
                        • Simpson-Angus Scale for parkinsonism
                        • Monitor for tardive dyskinesia (chronic EPS)
                        1. ✓

                           Outcome

                           EPS Managed

                           Ongoing prevention and monitoring

                           • Educate patient about EPS recognition
                           • Carry anticholinergic if high-risk
                           • Regular movement disorder screening
                           • Early intervention prevents complications
      2. ●

         Action

         Akathisia

         Inner restlessness, inability to sit still

         • Onset: Days to weeks after starting
         • Subjective inner restlessness
         • Pacing, rocking, inability to sit
         • Can be misdiagnosed as anxiety/agitation
         • Associated with suicidality if untreated
         1. ●

            Action

            Akathisia Treatment

            Beta-blockers or benzodiazepines

            • First-line: PROPRANOLOL 10-20mg TID
            • - Most evidence; well-tolerated
            • Alternative: LORAZEPAM 0.5-1mg BID-TID
            • Consider reducing antipsychotic dose
            • Anticholinergics less effective for akathisia
            • Mirtazapine 15mg may help
      3. ●

         Action

         Drug-Induced Parkinsonism

         Bradykinesia, rigidity, tremor

         • Onset: Weeks to months
         • Tremor (pill-rolling, resting)
         • Cogwheel rigidity
         • Bradykinesia
         • Masked facies
         • Shuffling gait
         1. ●

            Action

            Parkinsonism Treatment

            Anticholinergics or dose reduction

            • Reduce antipsychotic dose if possible
            • Switch to lower D2-binding SGA
            • BENZTROPINE 0.5-2mg BID
            • - Or trihexyphenidyl 2-5mg BID-TID
            • AMANTADINE 100mg BID alternative
            • Monitor for anticholinergic side effects