Augmentation of evaporative cooling is the treatment modality of choice because it is effective, noninvasive, and easily performed. Spray the naked patient with a mist of lukewarm water while air is circulated by large fans. Shivering may be suppressed with intravenous benzodiazepines such as diazepam 5 mg IV or Lorazepam 1-2 mg IV.
Other effective cooling methods are used less commonly. Immersing the patient in ice water results in rapid cooling, but complicates monitoring and access. Applying ice packs to the axillae, neck, and groin is effective, but is poorly tolerated in the awake patient. Cold peritoneal lavage results in rapid cooling, but it is an invasive technique that is contraindicated in pregnant patients or those with previous abdominal surgery. Cold oxygen, cold gastric lavage, cooling blankets, and cold intravenous fluids may be helpful adjuncts (Mecham, 2005). Alcohol sponge baths should be avoided because large amounts of the drug may be absorbed through dilated cutaneous vessels and produce toxicity (Khosla, 1999).
If supportive care and cooling measures are not successful in reversing the syndrome, drug therapy may be considered. “The efficacy of pharmacologic treatment of NMS has not been demonstrated in controlled trials, but the results of several case reports support their use. The major drugs that have been given are the dopaminergic agonist bromocriptine 2.5 to 7.5 mg PO every eight hours and dantrolene 0.8 to 3 mg/kg IV every six hours, up to a maximum of 10 mg/kg per day” (Mechem, 2005 p. 1). Dantrolene is beneficial primarily in cases of NMS involving significant rigidity and hyperthermia. It rapidly reduces extreme temperature elevations. These medications are effective during the first few days of treatment of NMS and are unlikely to show a delayed response (Caroff, www.mnsis.org).
ECT remains effective even late in the course of NMS, even after other interventions have failed. ECT is preferred if idiopathic lethal catatonia cannot be excluded, if NMS symptoms are refractory to other measures, in patients with prominent catatonic features, and in patients who develop a residual catatonic state or remain psychotic after NMS has resolved (Caroff, 2001).
It may take up to 7-10 days for NMS to completely resolve. Even longer for some of the many complications that can arise. The labs must be diligently monitored. The patient must be watched for developing complications such as DIC, rhabdomyolysis, or organ failure. Each complication must be treated appropriately in order to insure a positive patient outcome.
