Pass the CASC - Neuroleptic Malignant Syndrome - Script
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Scripted case study for explanation of Neuroleptic Malignant Syndrome to a father who's daughter has been admitted and receiving treatment for NMS. Pass the CASC exam gives real life scenario scripts to help with training for MRCPsych CASC course.
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Pass the CASC - Neuroleptic Malignant Syndrome - Script
- 2. Structure • Halo-Intro-Set the scene • Explanation of management decisions • Explanation of NMS • Explain present and future management plan • Explain hospital complaints procedure
- 3. Script: NMS and distressed father • “That certainly was not our intention she was here to be treated” • “She did experience a very serious reaction from the medications that were prescribed to her” • “As you know your daughter (NAME) was admitted to our ward because of the symptoms that she was suffering from” • “Her regular treatment was with an antipsychotic medication called Risperidone”
- 4. Script: NMS and distressed father • “However, when she was on the ward she became increasingly agitated as her symptoms were not being well controlled by the dose of Risperidone that she was on.” • “At the time she was assessed on the ward she was extremely agitated due to the symptoms she was experiencing and it was also felt that she was at risk to herself and also a potential risk to others on the ward.” • “That is certainly not the way we practice on this ward she was at risk and in major distress and a decision about her treatment required immediate attention”
- 5. Script: NMS and distressed father • “Although we always want to keep our patients on the minimum amount of medication possible, she was given an additional short-acting medication to help her called Haloperidol,” • “An increase in her Risperidone would have taken a few more days to act so prescribing Haloperidol in the short term was felt to be the appropriate option for her.” • “This was a standard choice of treatment and followed trust procedures as well as national guidelines which have been in practice for a number of years” • “There were no evident allergies or notes of any problems beforehand with (name) and it was therefore felt that we could provide her with our standard treatment with haloperidol
- 6. Script: NMS and distressed father • “She developed a reaction which was extremely rare called neuroleptic malignant syndrome I’m not sure if you’ve ever of heard that term before” • “Less than 2% of the patients on antipsychotics develop this condition” • “At the time when your daughter was given Haloperidol she was extremely agitated and needed to be stabilised quickly hence it was not felt appropriate to contact other family members at the time” • “It is an extremely rare side effect however was suspected early and she was immediately transferred to the nearest medical ICU”
- 7. Script: NMS and distressed father • “I am extremely saddened about the events that have occurred and cannot imagine how you must be feeling at the moment” • “We will be conducting a thorough investigation into the management of your daughter” • “You can certainly make a complaint and I can go over the complaints procedure with you with our ward manager” • “Any decision of starting medication will be based on her clinical presentation weighing the risks and benefits”
- 8. Script: NMS and distressed father • “We will be collaborating with her medical team and continue to have a shared plan as to how to treat her in the future” • “If she continues to require antipsychotic medication then we will carefully monitor her starting her at the lowest possible dose” • “Is there anything else you would like to ask me?”
- 9. Epidemiology • Rare/idiosyncratic side effect of anti psychotics, anti-parkinsonian and anti-depressants • 10-20% mortality rate due to failure of vital systems
- 10. Causes • Reduced dopamine activity and D2 receptor blockade. • Increased Ca release in muscle tissue • Quick adjustments of antipsychotic doses • Removal of anti-parkinsonian medication
- 11. Signs and symptoms • Not a comprehensive list – BE VIGILANT! • Fever • Autonomic dysfunction • Raised WBC • CPK • Confusion • Muscular Rigidity
- 12. Differentials • Catatonia • Malignant hyperthermia • Encephalitis or Meningitis • Parkinsonism • Serotonin syndrome • Septic shock • Poisoning eg ecstacy, cocaine
- 13. Investigations Simple: • ECG Complex: • FBC, CK, U&Es, LFTs, Blood cultures, Calcium and phosphate levels, Coagulation (DIC)
- 14. Management • Discontinue medications • Refer for Medical stabilization • Oxygen, IV fluids, ice packs • Dantrolene/Lorazepam/Bromocriptine
- 15. What do we do after? • Wait for all symptoms to resolve • Do they still need antipsychotics risks v benefits • Aggressive physical monitoring
- 16. What do we do after? • Structurally different antipsychotics eg avoid Clozapine if was on Olanzapine • No depots! • Warn about possible recurrence
- 17. Alternate Scenario • Discussion with Nurse/Consultant about management
- 18. Thank You! © 2012 All Rights Reserved And Asserted Under The Copyright Designs And Patents Act 1988 www.passthecasc.com
Editor's Notes
- Halo-Intro-Set the scene Allow them to vent if neccesary - relative venting Listen first and reiterate what you’ve heard – like with any angry patient however only need to reiterate if neccesary - to aid rapport and gain understanding of the situation Remember that they are going to be angry regardless of what you say to them! Explanation of management decision Reasons for admission and presentation of daughter > agitation due to psychosis > regular dosage of antipsychotic inadequate Explain reasons for treating with Haloperidol – level of risks Followed standard protocol Explain NMS – brief explanation rare condition Here there is a question of balance OF medico-legal and accepting responsibility - acknowledgement of the terrible situation and empathy round this at same time not accepting a responsibility in medico-legal sense Use of unpredictable is not quite right word –maybe a very rare side –effect –ideally be able to indicate figures and that problem was picked up early Here interviewer needs to state that treatment is standard and followed local procedures and national guidelines. There were no evident allergies or notes of any problems before. Use of empathy is required to try and maintain rapport Explain present and future management plan – lower dose / different class / vigiiant monitoring of symptoms NMS / mention collaboration with Medics from the beginning and continue to have a shared plan Explain hospital complaints procedure – help them with the complaints procedure full investigation We could argue that when he said that is she going to get better – “that’s something I would like to talk the medics about if there is no information on her prognosis” – it’s has a 10-20% mortality rate – would you say that? – need to check that one,
- Question of why haloperidol not used rather than lorazepam and increased risk of NMS with a second neuroleptic –not brought up here - “At this moment I am unclear as to why lorazepam was not used and haloperidol was – however we will be conducting a full investigation into what happened”
- Question of why haloperidol not used rather than lorazepam and increased risk of NMS with a second neuroleptic –not brought up here - “At this moment I am unclear as to why lorazepam was not used and haloperidol was – however we will be conducting a full investigation into what happened”
- Do you have children yourself- not sure what the best answer to that is but probably not to talk about oneself – “Mr.X I cannot imagine the stress you are under at the moment and appreciate why you ask me that – however I want to focus the discussion on the management of your daughter” / However, I do believe we made the only decision we could about her treatment at the time based on the risks and benefits – if really probed but don’t want to aggravate the situation
- Do you have children yourself- not sure what the best answer to that is but probably not to talk about oneself – “Mr.X I cannot imagine the stress you are under at the moment and appreciate why you ask me that – however I want to focus the discussion on the management of your daughter” / However, I do believe we made the only decision we could about her treatment at the time based on the risks and benefits – if really probed but don’t want to aggravate the situation
- Demographically, it appears that males, especially those under forty, are at greatest risk for developing NMS, although it is unclear if the increased incidence is a result of greater neuroleptic use in men under forty.[
- 1eg Resp, CVS. Increase in Ca2+ into sarcoplasmic reticulum secondary to antipsychotic use Number of different causes – just highlighted some here.. ? postpartum women may be at a greater risk for NMS ? An important risk factor for this condition is Lewy body dementia. These patients are extremely sensitive to neuroleptics. As a result, neuroleptics should be used cautiously in all cases of dementia.[edit]
- F – Fever A – Autonomic instability L – Leukocytosis T – Tremor E – Elevated enzymes (elevated CPK) R – Rigidity of muscles
- – lets have a quick think what you’d do to rule these out History, medical examination and investigations will help rule these out.
- (would they waste a scenario to test full medical management?) – no but they could have a linked station where you would have to discuss this with a consultant Discontinue medications that are suspected to have caused the condition Dantrolene/Lorazepam/Bromocriptine to reduce rigidity NMS is an emergency, and can lead to death if untreated. The first step is to stop neuroleptic drugs and to treat the hyperthermia aggressively, such as with cooling blankets or ice packs to the axillae and groin. Many cases require intensive care and circulatory and ventilatory support. Medications such as dantrolene sodium and bromocriptine may be used.[21] Apomorphine may be used however its use is supported by little evidence.[3] Benzodiazepines may be used to control agitation. Highly elevated CPK can damage the kidneys, therefore aggressive hydration may be required. Volume resuscitation is paramount. Benzodiazepines, dantrolene, and dopaminergic agents are a few pharmaceutical families that can be used to treat various degrees of NMS. If it is recognized early enough, NMS is not fatal, but still, 10% of cases do result in patient death.[2][edit]
- No others as yet. so they can look at your confidence in management of an emergency as well as knowledge of medical management…
- Be sure to pratice this as a 7 minute station