Extrapyramidal side effects develop due to the impact of antipsychotics on dopamine receptors in the extrapyramidal tract. Antagonism of D2 receptors leads to dopamine deficiency and acute or chronic movement disorders. Major extrapyramidal symptoms include neuroleptic-induced parkinsonism, acute dystonia, akathesia, tardive dyskinesia, neuroleptic malignant syndrome, and rabbit syndrome. Nurses are responsible for closely monitoring patients, administering treatments, and encouraging mobility to manage symptoms.

1. EXTRA PYRAMIDAL
SIDE EFFECTS
10/1/2020 eps 1

2. Introduction
•EPS develops due to the impact of antipsychotics on the
dopaminergic (D2) receptors in the extra pyramidal tract.
Dopaminergic antagonism effect on D2 receptors leads to
dopaminergic deficiency in the extra pyramidal tract leading to
acute or chronic movement disorders which are known as extra
pyramidal symptoms.
10/1/2020 eps 2

3. Extra pyramidal tract
10/1/2020 eps 3

4. Extra pyramidal system
• The term extrapyramidal system, coined by British neurologist Kinnier
Wilson, refers to the basal ganglia and an array of brain stem nuclei
(red nucleus, reticular formation etc.) to which they are connected.
• Components of the extrapyramidal system include the red nuclei,
vestibular nuclei, superior colliculus and reticular formation in the brain
stem, all of which project via discrete pathways to influence spinal cord
motor neurons.
• Cerebellar projections are also included since they influence not only
these brainstem motor pathways, but also the motor cortex itself via the
dentatothalamic projection.
10/1/2020 eps 4

5. Extra pyramidal system
Anatomy
• Basal Ganglia
• Neural Network that is part of the motor system
• Reticular formation of the pons and the medulla
• Nigrostriatal pathway
• Cerebellum
• Cerebral cortex- motor and sensory areas
10/1/2020 eps 5

6. 10/1/2020 eps 6

7. Extra pyramidal system
Other Functions
• Causes involuntary reflexes and movements
• Complex movements
• Postural control
10/1/2020 eps 7

8. 10/1/2020 eps 8

9. Major extrapyramidal symptoms
Neuroleptic induced parkinsonism
Acute dystonia
Akathesia
Tardive diskynesia
Neuroleptic malignant syndrome
Rabbit syndrome
10/1/2020
eps
9

10. Neuroleptic induced parkinsonism
Characteristics:
•cogwheel rigidity,
• tremors,
•bradykinesia (decreased movements),
•masklike face,
10/1/2020 eps 10

11. Neuroleptic induced parkinsonism
•stooped posture,
•drooling of saliva,
•slow gait,
•decreased armswing ,
•monotonous speech etc.
10/1/2020 eps 11

12. 10/1/2020 eps 12

13. 10/1/2020 eps 13

14. Neuroleptic induced parkinsonism
Common among: elderly, females.
•Treatment :
•Injection phenergan 12.5 / 25mg / 50mgIM
stat
•i. Start tab Pacitane/ tab phenergan
•ii. Soft diet
•iii. Plenty of fluids
10/1/2020 eps 14

15. 2. Acute dystonia
•Characteristics: painful spasm of neck, back,
jaw, tongue, leads to tongue protrusion,
torticollis, and opisthotonus, upward rolling of
eyes
•Common among : young men
10/1/2020 eps 15

16. Acute dystonia
Treatment :
 Injection Phenergan 12.5/ 25mg / 50mgIM stat
 Decrease dose of antipsychotics if possible
 Start tab Pacitane/ tab phenergan
 Soft diet
 Plenty of fluids
 Change antipsychotics to a group with less EPS
10/1/2020 eps 16

17. Acute dystonia
10/1/2020 eps 17

18. 10/1/2020 eps 18

19. 10/1/2020 eps 19

20. 10/1/2020 eps 20

21. 3.Akathesia
•subjective feeling of motor tension and restlessness or
inability stand/sit still.(patients gets a tendency to walk while
sitting and while walking tends to lie down, When lying
down tends like walking etc.)
•characteristics : inner sense of restlessness, fidgeting or
swinging of legs, pacing, inability to stand still for few
minutes (often misjudged as manic excitement)
10/1/2020 eps 21

22. Akathesia
Risk factors :high dose, rapid increase in dose, high potency drugs, older age
• females, iron deficiency etc.
Treatment :
 reduce antipsychotics
 If still persists switch to another antipsychotics
 Add benzodiazepines if not improving add Tab Propanalol 10/ 20mg
 Tab livogen (if iron deficiency is suspected)
10/1/2020 eps 22

23. 10/1/2020 eps 23

24. 4.Tardive dyskinesia
•Involuntary movement of tongue, lips, jaw, trunk ,
extremities leads to rapid jerky and non-repetitive
movements or repeated rhythmic oscillatory movements.
• Note :( gradual onset over a period of months to years, most
common among elderly females, typical antipsychotics)
10/1/2020 eps 24

25. Tardive dyskinesia
•Treatment :
•lower the dose of antipsychotics/ change the
antipsychotics
•Decrease/stop antipsychotics
•T.Tetrabenzine 25-100mg/day in divided dose
•T. Clonazepam 0.5mg-2mg/day in divided doses
10/1/2020 eps 25

26. • videoplayback.webm
10/1/2020 eps 26

27. Rabbit syndrome
•Rabbit syndrome is a rare form of extra-
pyramidal adverse effect of antipsychotic
medicines in which perioral tremors occur at a
rate of 4-5 Hz.
•Rabbit syndrome is characterized by involuntary,
fine, rhythmic motions of the mouth along a
vertical plane, without involvement of the tongue.
10/1/2020 eps 27

28. 10/1/2020 eps 28

29. Neuroleptic malignant syndrome
(LIFETHREATENING PSYCHIATRIC EMERGENCY)
• characterized by :muscle cramps and tremors, low to high grade
fever, unstable Blood pressure, alteration in the Level of
Consciousness, raised WBC, CPK, hypertensive crisis, metabolic
acidosis, hyperthermia, profuse sweating, muscle rigidity, intercostal
muscle spasm leads to dyspnoea leading to respiratory failure,
dysphagia.
10/1/2020 eps 29

30. Neuroleptic malignant syndrome
•Investigations : serum Calcium
( hypocalcaemia is common), ABG for
metabolic acidosis, LFT, CPK, urine
myoglobin, coagulation profile PT, APTT,
Chest X-Ray, CT Scan, Blood routine
•
10/1/2020 eps 30

31. Neuroleptic malignant syndrome
• Treatment :
• i. Mechanical ventilator support -ICU admission is mandatory
• ii. Stop all medications
• iii. IV Benzodiazepines
• iv. IV Fluids
• v. Antipyretics
• vi. Dopaminerigics : Bromocriptine/ Amantadine
• vii. Muscle relaxants
• viii ECT
10/1/2020 eps 31

32. Neuroleptic malignant syndrome
• TPR, I/O chart, BP chart ' Ensure adequate fluid and electrolyte balance I / V Fluids
• Temperature regulation PCM, cooling blanket, Tepid sponging
• Bromocriptine 2,5mg 1-0-1 to 1-1-1 (Maximum 45mg/day)
• Dantrolene 1mg/kg I / V X 8 days then orally X 7 more days
• Increase CPK, increase TC Refer to neuro medicine
• Mechanical Ventilation Benzodiazepam (Eg: Lorazepam 1-2mg IM or slow I/ V for
behaviouralmanagement/ sleep/agitation)
• Restart antipsychotics after giving enough time gap start another class With less
chance of EPS/NMS (Eg: Quetipine, Clozapine)
10/1/2020 eps 32

33. Nurses responsibility
• Assess the patient status.
• Reassure the patient and bystanders about the condition.
• Check the vital parameters temperature, pulse, respiratory rate, blood
pressure.
• Inform the doctor.
• Closely monitor the patient.
• Plenty of oral fluids are encouraged.
• Immediately carry out the treatment orders. For eps
• After shifting the patient from ICU to ward; admit the patient to the
isolation room.
•
1 0/1/2020 eps 33

34. • Close monitoring is needed
• Check the Vitals 4th hourly
• Administer IV fluid as per order
• If patient is on ryles tube feeding: provide ryles tube feeding
every 2hrly. After gag reflux has returned, start oral feed,
semisolid, solid, liquid foods Always elevate the head end while
feeding the patient to avoid aspiration.
• Encourage plenty of fluids if orally tolerated
• Positioning and back care is needed for sick/ bedridden patient.
• Slowly encourage the patient to walk. Ambulation is encouraged
once thepatient’s condition improves.
10/1/2020 eps 34

35. •CONCLUSION
•EPS develops due to the impact of antipsychotics on the
dopaminergic (D2) receptors in the extra pyramidal
tract. Dopaminergic antagonism effect on D2 receptors
leads to dopaminergic deficiency in the extra pyramidal
tract leading to acute or chronic movement disorders
which are known as extra pyramidal symptoms.
10/1/2020 eps 35

36. •Thank you….
10/1/2020 eps 36