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Immediate stabilization
Time critical priorities
Offending agents held immediately
Dopamine receptor antagonists stopped
Dopaminergic agents restarted if withdrawal trigger
Airway and ventilation
Aspiration risk with hypersalivation and obtundation
Neuromuscular rigidity contributing to respiratory failure
Temperature control
Active external cooling
Antipyretics not reliable for hyperthermia physiology
Circulation and perfusion
Isotonic crystalloid for hypovolemia from diaphoresis
Vasopressor support for persistent shock after fluids
Monitoring and early actions
Monitoring bundle
Core temperature monitoring
Rectal or esophageal probe for severe hyperthermia
Trend every 15-30 minutes during active cooling
Cardiorespiratory monitoring
Continuous ECG for dysrhythmia risk
Continuous pulse oximetry
Urine output monitoring
Foley for rhabdomyolysis risk and immobility
Target urine output 1-2 ml/kg/hour if rhabdomyolysis
Sedation strategy
Benzodiazepines preferred for agitation and rigidity
Avoid antipsychotics for agitation control
Key decision points
Diagnostic pivot points
Hyperthermia with rigidity plus dopamine antagonist exposure
Neuroleptic malignant syndrome favored
Early presentations without fever possible
Clonus and hyperreflexia
Serotonin syndrome favored
NMS less likely without lead pipe rigidity
Recent anesthesia with succinylcholine or volatile agent
Malignant hyperthermia favored
Rapid onset minutes to hours
Consultation triggers
Team activation
ICU consultation
Any hyperthermia with rigidity and altered mental status
Rising creatine kinase or end organ dysfunction
Toxicology consultation
Polypharmacy or unclear toxidrome
Guidance on dantrolene or dopaminergic therapy
Psychiatry consultation
Malignant catatonia overlap
Reintroduction plan for antipsychotic therapy
Neurology consultation
Parkinsonism hyperpyrexia syndrome concern
Alternative neurologic diagnoses on exam
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.