Acute Dystonic Reaction

1. Acute Dystonia
Ade Wijaya MD, November 2021

2. Outline:
• Definition
• Etiology
• Clinical presentation
• Evaluation
• Treatment/management
• Differential diagnosis

3. Definition of Dystonia
• Involuntary contractions of muscles either
sustained or intermittent patterns that lead to
abnormal movements or postures
Lewis K, O'Day CS. Dystonic Reactions. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan

4. Etiology
• Drug induced
• Dopamine receptor-blocking agents
• Dopaminergic-cholinergic imbalance in the
basal ganglia.
Lewis K, O'Day CS. Dystonic Reactions. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan

5. Clinical Presentation
• Buccolingual Crisis - trismus, risus sardonicus, dysarthria, dysphagia, grimacing, tongue
protrusion
• Oculogyric Crisis - spasm of the extraocular muscles, most commonly deviated upward
• Torticolic Crisis - abnormal asymmetric head or neck position
• Tortipelvic Crisis - abnormal contractions of the abdominal wall, hip, and pelvic
musculature
• Opisthotonic Crisis - characteristic flexion posturing with arching of the back
• Laryngeal Dystonia - dysphonia, stridor
• Pseudomacroglossia - patient describes the sensation of tongue swelling and protrusion
Lewis K, O'Day CS. Dystonic Reactions. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan

6. Evaluation
• Airway, breathing, and circulation
• History and physical examination
• Special attention should be given to recently
administered medications
Deik A, Saunders-Pullman R, Luciano MS. Substance of abuse and movement disorders: complex interactions and comorbidities. Curr Drug Abuse Rev. 2012 Sep;5(3):243-53.

7. Treatment/Management
First line:
• Diphenhydramine: 50 mg intravenous (IV) in
adults and 1 mg/kg up to 50mg IV in pediatric
patients followed by oral route every 6 hours for
1 to 2 days to prevent recurrence of symptoms.
• Benztropine: a single dose of 1 to 2 mg IV
followed by 1 to 2 mg by mouth twice a day for
up to 7 days to prevent a recurrence
Lewis K, O'Day CS. Dystonic Reactions. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan

8. Treatment/Management
Second line:
• IV or IM lorazepam at 0.05 to 0.10 mg/kg or IV
diazepam at 0.1 mg/kg
Lewis K, O'Day CS. Dystonic Reactions. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan

9. Differential Diagnosis
• Conversion disorder
• Tetanus
• Focal seizure
• Strychnine poisoning
• Hypocalcemia
• Anticholinergic toxicity
• Meningitis
• Neuroleptic malignant syndrome
• Stroke
• Temporomandibular joint dislocation
• Mandibular fracture
• Orbital fracture
• Clonus
Lewis K, O'Day CS. Dystonic Reactions. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan