Astute assessment results in quick action.
- Acute dystonic reactions, which include sudden muscle spasms, can occur with dopaminergic medications, most commonly antipsychotics and antiemetics.
- Prompt recognition of an acute dystonic reaction helps to ensure patient recovery and prevention of potential irreversible tardive dyskinesias.
- Treatment includes discontinuation of the causative agent when possible and anticholinergic medications (typically diphenhydramine or benztropine).
Shawn Brown*, a 32-year-old man, is admitted to the med–surg unit after an emergency appendectomy. Report from the post-anesthesia care unit (PACU) includes post-op nausea treated with metoclopramide 10 mg I.V. an hour before his arrival and subsequent relief of symptoms. His vital signs have remained within normal parameters in the PACU.
Mr. Brown’s history includes schizoaffective disorder and type 2 diabetes. He vapes nicotine and takes metformin daily, injects dulaglutide weekly, and injects long-acting fluphenazine decanoate every 3 weeks. The last fluphenazine decanoate injection occurred 4 days ago.
Managing delirium in the pediatric patient
Avoiding antipsychotic medication use in nursing home residents with dementia
At the bedside
Amal, the med–surg nurse, notes a slight left turning of Mr. Brown’s head during her admission assessment, but Mr. Brown says that he hasn’t noticed or felt this. The patient’s vital signs remain within normal parameters. He has incisional pain and receives ketorolac 15 mg I.V. Thirty minutes later, Amal enters Mr. Brown’s room and observes a significant left head turn and upward turned eyes. The muscle spasm is so painful that Mr. Brown can’t turn to the right, which causes him significant distress.
While remaining at the bedside, Amal contacts the hospitalist and provides situation, background, assessment, and recommendation report. The hospitalist orders a stat dose of diphenhydramine 50 mg I.V. and arrives at the bedside for further assessment.
Outcome
Within 15 minutes of receiving diphenhydramine, Mr. Brown moves his neck freely and no longer has an upward gaze. The hospitalist determines that Mr. Brown experienced an acute dystonic reaction to metoclopramide, with the recent fluphenazine injection a possible contributing factor. The hospitalist orders diphenhydramine 50 mg I.V. every 6 hours until the patient can tolerate oral intake; he will take the medication by mouth until discharge.
The hospitalist consults with Mr. Brown’s outpatient psychiatrist, who advises prescribing oral benztropine 1 mg twice daily throughout his hospitalization. On post-op day one, Mr. Brown can ambulate, tolerate an advanced diet, and has no further dystonic symptoms. He’s discharged the morning of post-op day two and has appointments scheduled with his psychiatrist and surgeon.
Education
Acute dystonic reactions, movement disturbances, fall under the umbrella of extrapyramidal side effects. They’re associated with medications (including antipsychotics and antiemetics) that mediate dopamine. Symptoms include intermittent or sustained muscle contractions of the face, jaw, neck, torso, or limbs, which result in abnormal movements or postures. These spasms can range from mild to severe; patients can find them distressing and painful. All other vital signs and general assessments will appear normal. Dystonia of the larynx can affect airway patency and requires calling a rapid response.
Resolution of acute dystonia requires quick recognition and treatment, which includes discontinuation of the offending agent and prompt treatment with anticholinergics to prevent possible tardive dyskinesias. Being aware of recent evidenced-based practices and applying them to a patient’s unique medical history and needs can mitigate the risks of adverse events. Patients who require antipsychotic medications to treat serious mental illness require co-management with psychiatry service while hospitalized and close outpatient follow-up.
Patient and family education can help prevent future dystonic reactions. Education should include information about medications that can increase risks and the importance of following up with their psychiatrist for ongoing evaluation and management.
*Names are fictitious.
Jamie Bourgeois is a PhD student at UMass Tan Chingfen Graduate School of Nursing in Worcester, Massachusetts, and works as a PMHNP-BC in the children and adolescent department of the Mental Health Center of Greater Manchester in Manchester, New Hampshire.
American Nurse Journal. 2025; 20(1). Doi: 10.51256/ANJ012553
References
Daripa B, Lucchese S. A rare case of domperidone-induced acute dystonia in a young adult due to consumption of combination drug (proton pump inhibitors with domperidone) and its possible pathomechanism. Cureus. 2022;14(4):e23723. doi:10.7759/cureus.23723
Rissardo JP, Vora N, Mathew B, et al. Overview of movement disorders secondary to drugs. Clin Pract. 2023;13(4):959-76. doi:10.3390/clinpract13040087
Rogers JP, Dobbs RJ, Dobbs S. Acute dystonia. In: Taylor DM, Gaughran F, Pillinger T, eds. The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry. Hoboken, NJ: John Wiley & Sons; 2021:673-7.
Key words: dystonia, acute dystonic reaction, extrapyramidal side effects, psychiatric mental health nursing
