The causative agent should be stopped
Discontinue all dopamine blocking agents
If precipitant is a dopaminergic therapy (L-dopa or Carbidopa) it can be restarted later at lower doses as an outpatient
Agitation should be controlled with Benzodiazepines
Lorazepam 2 mg IV q5 min until agitation and muscle rigidity resolves
Fluid resuscitation
Cooling measures
Intubation and paralysis for severe cases, chest wall rigidity or respiratory failure
Use NON-DEPOLARIZING paralytic agent
Lorazepam 2 mg IV q5 min until agitation and muscle rigidity resolves
Use NON-DEPOLARIZING paralytic agent
Controversial with unclear and disputed efficacy
Dantrolene (skeletal muscle relaxant) - Consider only in patients with severe rigidity
May cause hepatotoxicity in patients with liver disease
0.25-2mg/kg IV q6-12hr, max dose 10mg/kg/day
Bromocriptine (dopamine agonist)
2.5mg PO q6-8hr, max dose 40mg/day
Amantadine (alternative to bromocriptine)
100mg PO initially; titrate up as needed to max dose 200mg q12hr
May cause hepatotoxicity in patients with liver disease
0.25-2mg/kg IV q6-12hr, max dose 10mg/kg/day
2.5mg PO q6-8hr, max dose 40mg/day
100mg PO initially; titrate up as needed to max dose 200mg q12hr
Limited case series suggest that ECT can be effective in<unk>  refractory to pharmacotherapy
Neuroleptic malignant syndrome
Serotonin Syndrome
Limbic encephalitis
Serotonin syndrome more likely to have hyperreflexia, myoclonus, ataxia, nausea and vomiting, diarrhea
Osmotic demyelination syndrome
Rigidity and hyperthermia, if present, is less severe than in NMS; more commonly presents with clonus and hyperreflexia
Posterior reversible encephalopathy syndrome
Malignant Hyperthermia