Neuroleptic malignant syndrome

Rigidity, hyperthermia, diaphoresis, autonomic instability, recent antipsychotic start/increase

EmergentReview due

Compare (8)

At a glance

High risk: Yes
Onset: Days
Course: Progressive
Treatable: Yes

Safety snapshot

Hyperthermia, rising CK, AKI, collapse, severe autonomic instability.

Watch forRhabdomyolysisAKIcollapsedeathHyperthermiarising CK

Presentation hinge

Characteristic motor syndrome rather than simple low mood, psychosis, or "behavioural refusal". Mood disorders are a very common substrate.

Separates the Medication Side Effects / Iatrogenic Toxicity / QT Risk group. It is not specific to Neuroleptic malignant syndrome.

Do now

1Immediate cessation of all dopamine receptor antagonists, including all antipsychotics and antiemetics (e.g., metoclopramide, prochlorperazine)
2Initiate intensive medical care with aggressive IV hydration targeting urine output to prevent acute tubular necrosis from rhabdomyolysis, combined with active cooling
3Initiate specific pharmacotherapy: bromocriptine (dopamine agonist) and/or dantrolene (skeletal muscle relaxant) under intensivist or toxicology guidance
4Escalate immediately to intensive care for continuous cardiac monitoring for arrhythmias, respiratory support, and serial monitoring of CK and renal function
5Document the implicated dopamine antagonist clearly and ensure it is flagged as an adverse drug reaction across all clinical records

Locally authored, reviewed by PsychSift on 6 October 2026

Clinical review

Rows marked “Whole group”: Applies to the Medication Side Effects / Iatrogenic Toxicity / QT Risk group — not specific to Neuroleptic malignant syndrome

Why it fits

Rigidity, hyperthermia, diaphoresis, autonomic instability, recent antipsychotic start/increase

Key features2 features

Rigidity, fever, autonomic instability, confusion after dopamine blockade or withdrawal
Temporal association with antipsychotic initiation, dose change, or depot timing.

Must-not-miss

Hyperthermia, rising CK, AKI, collapse, severe autonomic instability.

High-risk causes7 causes

Rhabdomyolysis
AKI
collapse
death
Hyperthermia
rising CK
severe autonomic instability

Bedside question

Applies to the Medication Side Effects / Iatrogenic Toxicity / QT Risk group.

Characteristic motor syndrome rather than simple low mood, psychosis, or "behavioural refusal". Mood disorders are a very common substrate.

Helpful clues1 clue

Temporal association with antipsychotic initiation, dose change, or depot timing.

Immediate action

Applies to the Medication Side Effects / Iatrogenic Toxicity / QT Risk group.

Constipation with clozapine is a red flag, not a nuisance side effect Clozapine constipation and myocarditis are high-risk problems Escalate early, review bowels deliberately, maintain active surveillance during early titration Early activation is a common misread Clinical toxicity can occur even when history suggests a "usual dose" Check ammonia if unexplained confusion develops on valproate

Priority steps8 steps

1Constipation with clozapine is a red flag, not a nuisance side effect
2Clozapine constipation and myocarditis are high-risk problems
3Escalate early, review bowels deliberately, maintain active surveillance during early titration
4Early activation is a common misread
5Clinical toxicity can occur even when history suggests a "usual dose"
6Check ammonia if unexplained confusion develops on valproate
7Use structured screen (Bush-Francis), examine motor signs, check vitals/hydration/CK, think benzodiazepine challenge early
8Catatonia is more often mood-linked than many clinicians expect

Investigations

Applies to the Medication Side Effects / Iatrogenic Toxicity / QT Risk group.

Vitals, oxygen saturation, Creatine kinase, Neuroimaging (CT/MRI), EEG, Lumbar puncture / CSF studies

Core tests8

ECG / QT assessment
Urea, electrolytes, creatinine
Inflammatory markers (CRP/ESR)
Creatine kinase
Vitals, oxygen saturation
Neuroimaging (CT/MRI)
EEG
Lumbar puncture / CSF studies

Mimics / overlap

Applies to the Medication Side Effects / Iatrogenic Toxicity / QT Risk group.

None listed

Consider

Do now

1Immediate cessation of all dopamine receptor antagonists, including all antipsychotics and antiemetics (e.g., metoclopramide, prochlorperazine)
2Initiate intensive medical care with aggressive IV hydration targeting urine output to prevent acute tubular necrosis from rhabdomyolysis, combined with active cooling
3Initiate specific pharmacotherapy: bromocriptine (dopamine agonist) and/or dantrolene (skeletal muscle relaxant) under intensivist or toxicology guidance
4Escalate immediately to intensive care for continuous cardiac monitoring for arrhythmias, respiratory support, and serial monitoring of CK and renal function
5Document the implicated dopamine antagonist clearly and ensure it is flagged as an adverse drug reaction across all clinical records

Locally authored, reviewed by PsychSift on 6 October 2026

First-line tests

Applies to the Medication Side Effects / Iatrogenic Toxicity / QT Risk group — not specific to Neuroleptic malignant syndrome

ECG / QT assessment
Urea, electrolytes, creatinine
Inflammatory markers (CRP/ESR)
Creatine kinase
Vitals, oxygen saturation

Watch for

Rhabdomyolysis
AKI
collapse
death
Hyperthermia
rising CK

Also consider

Source and review

Review due· Unverified

v10 · exported 2026-07-11

Clinical reference — not validated decision support. Review before use.