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Emergency / Toxicology · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Started haloperidol injections 5 days ago; now T 40.2 °C, lead-pipe rigidity, confusion, sweating, labile BP; CK 18,000 U/L
Red flags Temperature >40 °C CK >10,000 with AKI BP swings/arrhythmia Aspiration Differential diagnosis Serotonin syndrome Malignant hyperthermia (anaesthesia) Meningitis/encephalitis Heat stroke Anticholinergic toxicity Lethal catatonia When to admit, call ICU or discharge Admit: All suspected NMSICU: Temperature >40 °C, severe rigidity, autonomic instability, AKI, respiratory compromiseDialysis: AKI from rhabdomyolysis with AEIOU indicationsKey points Serotonin syndrome: rapid onset, clonus and hyperreflexia, diarrhoea → cyproheptadine; NMS: slow onset, bradyreflexia, lead-pipe rigidity. Mortality is now ~5–10% with early recognition. Depot antipsychotics prolong the course. Never Continue or restart the antipsychotic during NMS Give anticholinergics expecting them to help (they worsen heat) Rechallenge within 2 weeks Miss infection (meningitis/encephalitis) as the cause of fever and confusion Common mistakes Not cooling Confusing with serotonin syndrome Early rechallenge Missing infection Disposition and follow-up ICU for severe cases; psychiatry-led rechallenge planning.
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