A 20-year-old man started on haloperidol 5 mg/day three days ago presents to the emergency department with torticollis, upward deviation of the eyes, and jaw clenching. He is conscious and distressed. What is the immediate next step?

• A Start benztropine 2 mg orally daily as maintenance therapy
• B Order an urgent MRI brain to exclude basal ganglia pathology
• C Stop all antipsychotics permanently and switch to clozapine
• D Administer intramuscular promethazine 50 mg and observe ✓

Explanation

This is an acute dystonic reaction, typically within days of starting a high-potency typical antipsychotic, more common in young males. The emergency treatment is parenteral anticholinergic or antihistaminic such as IM promethazine or IV benztropine, followed by oral prophylaxis. Oral maintenance benztropine alone is too slow for an acute crisis. Stopping antipsychotics permanently and MRI are unnecessary since the reaction is drug-induced and self-limited with treatment.

Reference: Katzung's Basic and Clinical Pharmacology, 16th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.