Assessing for Neuroleptic Malignancy Syndrome, Serotonin Syndrome, or Anticholinergic Syndrome

Assess non-specific symptoms 

Hypertension 
No Re-evaluate patient case
Tachycardia
Tachypnea
hyperthermia  Mild Symptoms: flushing, dry skin,
mydriasis, urinary retention

Yes

Does patient have any of the following:

D/c medication, supportive care
and monitor for symptoms
Dry mucous membranes (dry mouth)
erythema Does patient take one or
Yes Yes Likely Anticholinergic Syndrome
dry and hot to touch more anticholinergic medicationsa

decreased or absent bowel sounds

Hyperthermia 38oC No Refer patient patient to ER

No Likely not ACS: reassess case

Mod-Sever Symptoms: hallucinations,
Does patient have 1 or  more: 
delirium, psychosis, seizures
Reassess case
No
diaphoresis
moist mucosa

Yes
Likely not SS: reassess case

Does patient have one or  more of the following symptoms:

No
spontaneous clonus 
inducible clonus AND agitation or diaphoresis  Does patient take one or more Manage: Refer patient to ER.
ocular clonus AND agitation or diaphoresis  Yes Yes Likely Serotonin Syndrome
serotonergic medicationsb  D/c offending medicationsb 
tremor AND hyperreflexia 
hypertonia AND temperature above 38’C AND
ocular or inducible clonus

No
Manage: Refer
patient to ER, D/c
Does patient have 1 or more of  the following Yes Likely NMS offending
symptoms:

medicationc,
lead pipe rigidity present in all muscle
groups Is patient taking antipsychotic/D2
bradyflexia Yes
Antagonist medicationsc
mutism, stupor,
Temperature >38oC
Catatonia 
No Likely not NMS: Reassess case

[a] Anticholinergic Medications

[b] Serotonergic Medications [c] D2 Antagonist Medications

Amphetamines
Antihistamines (dimenhydrinate etc.) MOAI: Meclobemide etc.
Typical antipsychotics: Chlorpromazine,
Tricyclic antidepressants (clomipramine, etc.)  SSRI: Sertraline, Citalopram etc. Fluphenazine, Haloperidol, Loxapine, Perphenazine,
Sleep aids (diphenhydramine etc.) SNRIs: Venlafaxine, Duloxetine etc. Thiothixene
Cold preparations (Tylenol PM)  TCA: Clomipramine etc. Atypical antipsychotics: Aripiprazole, Clozapine,
Scopolamine  Illicit drugs: LSD, ecstasy, Magic Mushrooms Olanzapine, Paliperidone, Quetiapine, Risperidone,
Atropine Opioids: Tramadol, buprenorphine  Ziprasidone
NHPs: St. John's Wort Lithium (incombo w/antipsychotics)
Cough and Cold Prep: Dextromethorphan etc. Antiemetics: Metoclopramide, Prochlorperazine,
Promethazine, Reserpine