Zurab kheladze & zviad kheladze critical care medicine hand book

Zurab Kheladze & Zviad Kheladze Critical Care Medicine HAND BOOK Mental disorders Febrile schizophrenia, malignant neuroleptic syndrome Occurs spontaneously and is the result of hypertoxic or febrile schizophrenia (lethal catatonia). Sometimes it is presented as a drug complication – malignant neuroleptic syndrome. Clinical presentation is same for both of them and have general name of febrile schizophrenia. The term belongs to Skeid and was first used in 1937. Other names are also used: "Bell" mania, fatal hysteria, acute azotemic psychotic encephalitis, acute delirium, "grave" mania and etc. Using these names such clinical case is described which is analogue to a febrile and lethal schizophrenia. Malignant neuroleptic syndrome was first described in 1960 by J. Delei. Mortality is high during malignant neuroleptic syndrome, it approaches 40% and rate of its development on the background of neuroleptic treatment is 3-27%. Pathogenesis: One of the versions of oneiroid catatonia and particular form of psychosomatic disorder with different etiology. It is accompanied by the disturbance of consciousness. During pathogenesis hyperergia is a peculiarity which determines hypothermic disturbances, included there hypertoxic and lethal species. Etiology and pathogenesis of hypertoxic state is not fully studied. There are different theories for development of hypertoxic schizophrenia. Main point is the presence of malignant hyperthermia in the clinical picture. Following forms of disease are presented: • Febrile attacks of schizophrenia; • Generalized toxic-allergic reactions; • Acute drug intolerance; • Mixed states during which acute attacks of febrile schizophrenia is complicated with toxic- allergic reaction to neuroleptics, critical rise of hyperthermia and development of bullous dermatitis. It is not known whether somato-vegetative status defines and programs following clinical syndromes or somato- vegetative state just accompany urgent psychic states. Malignant neuroleptic syndrome develops in both sexes with different age groups during the treatment with neuroleptics. Especially high extra pyramidal activity and selective antypsychic action has haloperidol, triptazine, thioproperazine, decanoate (fluphenazine). During the usage of depo neuroleptics, syndrome is more severe. It develops in 3-4 weeks after the treatment with neuroleptics. It can also develop after sudden stoppage of psychotropic medications. After developing malignant neuroleptic syndrome in the anamnesis there is always attacks of various types of schizophrenia. Cerebral pathology (skull and brain trauma, lack of psychical Critical Care Medicine HAND BOOK Zurab Kheladze & Zviad Kheladze Critical Care Medicine HAND BOOK development caused by perinatal pathology, CNS infections and etc.) physical exhaustion, dehydration and high environmental humidity contribute to its development. Its development can also be contributed by the damage of blood-brain barrier, getting brain antigens in blood, anticerebral autoimmunization and by immune aggression on the brain. As a result develops so called – "cerebral shock", in its clinical picture psychic disorders are combined with poly organ and poly system failure. Development of malignant neuroleptic syndrome can also be caused by the blockage of dopaminergic structures in hypothalamus and basal ganglia and not by the direct toxic effect of neuroleptics. Hyperthermia is the result of muscle rigidity and hyper metabolic status. Clinical presentation: Attack of febrile schizophrenia is sudden. It is characterized by generalized muscle rigidity, which is accompanied by different depth of disturbance of consciousness. Dehydration and disturbance of homeostasis: It is characterized by tremor, discinesia, dysphagia, hypersalivation, hyperhydrosis, tachycardia, and hypertension. Hypertension occurs on an early stage. At first temperature is subfebrile, rises gradually and reaches febrile and hypertoxic rate on the first day. Temperature curve is irregular type: febrile and hypertoxic episodes meet at different times and between them subfebrility is maintained. For malignant neuroleptic syndrome on an early stage manifestation of extrapyramidal symptoms with extrapyramidal-catatonic type is characteristic. In a clinical picture catatonic disturbances are manifested (stupor, catalepsy and negativism). Tachycardia (>140) dissociates with body temperature. Early manifestation of temperature-pulse dissociation is an indicator of hypertoxic schizophrenia. Patients have characteristic appearance: face green-ground color, rarely pale or hyperemic, prominent facial features, sunken eyes, sclera initiation, gaze is scattered or fixed in one place, forehead is covered with sweat, mucous is dry, white or brown patches on tongue, extravasation on skin and mucous. Trophic disturbances in the form of bedsore are frequent. Bad prognostic factor for malignant neuroleptic syndrome is bullous dermatitis. Profuse sweating on the first day of febrile schizophrenia changes by exicosis symptoms. Patient's general somatic state worsens manifesting depression, hypotonia, bradycardia, acute respiratory failure. Main reason of death is cardiovascular failure due to growing brain edema. Diagnosis: Differentiation should be made with other diseases manifesting fever, such as flue, malignant hyperemia and etc. Attention should be paid to the existence of catatonic and other psychopathologic disturbances in the form of delirium or hallucination syndrome. It should be foreseen, that during malignant neuroleptic syndrome stoppage of neuroleptics improves Critical Care Medicine HAND BOOK Zurab Kheladze & Zviad Kheladze Critical Care Medicine HAND BOOK condition and on the contrary during febrile schizophrenia neuroleptic therapy improves condition. Diagnostic criteria for malignant neuroleptic syndrome are following: during neuroleptic treatment development of muscle rigidity and hyperthermia. Also two or more accompanying symptoms: hyperhydrosis, dysphagia, tremor, dysuria, loss of consciousness, mutism, tachycardia, increase of arterial pressure, leukocytosis and increase of CPK. First and second groups of symptoms should not be the result of psychopathology state presenting with catatonic symptoms (catatonic form of schizophrenia, affective disorder presented with catatonic symptoms). Herewith, first and second groups of symptoms should not be the result of neurologic disease (viral encephalitis, vascular or mass related injury), also the result of taking other medications with similar clinical presentation (phencyclidine, amphetamines, MAO inhibitors, dopaminergic structure blocker). Treatment: Treatment of febrile attacks of schizophrenia is not fully developed. Treatment with aminasin is indicated. Haloperidol, phrenolon, tisercin are also effective. Since the 1970 electroimpulsive therapy is used, but by present results such therapy is effective only after third session and in case if treatment is started on the first day of disease development. If diagnosis is late using 225mv strain and by 0.8 sec. exposition discharge of seizure is impossible because of hypo and non reactive brain structures and brain edema. Since 1980 for the treatment of malignant hyperthermia extracorporeal detoxification method is provided: hemosorbtion, plasmapheresis and hemodialysis. In the modern era treatment of febrile schizophrenia is complex and includes electro impulsive therapy, neuroleptics, infusion therapy (crystalloids, colloidal and fresh frozen plasma), hormone therapy, cardiotonic and diuretic therapy and use of artificial lung ventilation when necessary. Therapy for brain edema includes hyperventilation and osmodiuresis. It should be started after the manifestation of first clinical signs (headache, vomiting, meningeal signs, disturbance of ocular motor innervations – changing mydriasis into miosis, decrease of photo reaction, vestibular disturbances – nystagmus, seizure discharges and etc.) On the first day of disease increase in arterial pressure is characteristic, which does not need any specific treatment. After depression of blood circulation it is important to start inotropes and vasopressors, alpha agonists should be used by individual selection of standard doses. It is possible to combine it with hormones. Indication for heparin and its analogue use is hypercoagulation state. Decrease of hyperpyrexia is accomplished by the combination of physical and chemical methods: parenteral antipyretic medications, cooling of body by physical methods and etc. For psychomotor excitation benzodiazepines and barbiturates can be used. There combination gives sedative effect and makes possible stopping of catatonic excitation. Critical Care Medicine HAND BOOK Zurab Kheladze & Zviad Kheladze Critical Care Medicine HAND BOOK Such therapy decreases rigidity and hyperthermia, has anti hypoxic effect – increases brain and other organs tolerance to the oxygen requirement. In this regard midazolam group of drugs can be used. Prophylaxes of intercurrent infections include treatment with antibiotic. Adequate nutrition is very important to ensure that body maintains normal level of energy balance during increased metabolism and hypercatabolism, daily requirement 3000-3500 kcal. During the deep disturbance of consciousness on the background of febrile schizophrenia attack, during the change of oneroidal-catatonic status into amentic status, manifests different depth of coma. During febrile period use of neuroleptic medications is not recommended because of the negative side effects and complications. Adding neuroleptics to the treatment is necessary after ending febrile attacks, especially during delirium and hallucination syndrome. During malignant neuroleptic syndrome it is necessary to: • Stop neuroleptic medications • Prescribe dopamine receptor agonist-bromocriptine, enterally by nasogastric tube, 7.5-60mg/daily dose. • Prescribe dantrolene (muscle relaxant, striated muscle tissue, sarcoplasmic reticulum calcium channel blocker) 1-2mg/kg dose. • Other treatment is identical to treatment for febrile schizophrenia. Prognosis: in 70% of cases is unreliable (mortality is frequent during febrile schizophrenia with malignant form, when hyperthermia is >41°C). 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