You’re working in the resus room, and a code stroke is called in.  She arrives, and rather than any weakness, numbness, or facial droop, you see an elderly, unkempt woman who looks like she’s made of stone.  Her mouth is open and drooling, and she severe cogwheeling when you try to extend her arms.  She does not know where she is, and she thinks that it’s 1974.  Her BP and HR keep fluctuating from normal to extremely high values.  She is afebrile.  Her daughter states that at baseline, her mother is AAOx3 and has no movement disorders.  She also mentions that her mother was discharged home two weeks ago from the psych unit for schizophrenia, where she received a Haldol depot shot.  She is still taking her regular dose of haldol at home as well.  On lab tests, she was found to have a CPK of 2000 and a Cr of 1.5 (increased from 0.7).

What do you think this woman had?  (Scroll down)

Neuroleptic Malignant Syndrome:  This is a life-threatening reaction from antipsychotic and certain antiemetic agents (ex. reglan).  20% mortality rate.  Haldol is a big risk factor (typical antipsychotic, high potency).  NMS usually occurs within 2 weeks of starting a drug, but it has been known to occur with doses that have been stable for years.  Our patient had just had a depot shot and mistakenly kept taking her PO dose as well.

Characterized by 4 signs: AMS, rigidity, fever, and autonomic dysfunction.  These signs EVOLVE over 1-3 days, so you may not see all the signs on presentation.  AMS usually occurs first, followed by rigidity.  You need 2/4 signs to diagnose.

Pneumonic: FALTER (Fever, Autonomic dysfunction, Leukocytosis, Tremor, Elevated CPK, Rigidity).


1) Stop the causative agent and other possible contributory agents (lithium, serotonergic agents).

2) Supportive care – hydration, fix electrolyte abnormalities, intubate if needed (chest wall rigidity), monitor for ARF, MI, liver failure, DVT/PE.

3)  Cooling blankets if neeeded.  BP control (no preferred agent).

4)  Specific agents have been used in case reports and may decreased time to recovery, but there are no large trials:

-Dantrolene – Skeletal muscle relaxant, 1-2mg/kg, onset time of minutes. Avoid if LFTs are very abnormal

-Bromocriptine – Dopamine agonist, 2.5mg PO.

-Amantadine – Dopamine agonist and anticholinergic agent. 100mg PO.

5) ECT as a last-ditch effort.

May 2024