Abstract
Since the development of antipsychotic drugs in the 1950s, a variety of studies and case reports have been published that suggest an association between exposure to typical antipsychotics and venous thromboembolisms (VTE). Therefore, when starting treatment with antipsychotics, especially low-potency typical antipsychotics and clozapine, health-care providers must account for the patient's existing VTE risk factors. In this case report, the authors describe the development of a pulmonary embolism associated with use of chlorpromazine in the treatment of an acute manic episode in a 51-year-old female patient with bipolar disorder type 1. The patient was brought to the emergency room by the police on a legal hold for bizarre behaviors at a bus stop, which included incessantly yelling at bystanders. The patient was found to have disorganized thoughts, poor sleep, rapid speech, labile mood, distractibility, auditory hallucinations and grandiose delusions. During the course of her stay, the patient received extensive IM chlorpromazine for extreme agitation, in addition to chlorpromazine 200 mg IM Q8H, which was later decreased to chlorpromazine 100 mg chlorpromazine IM/PO Q8H. On day 4 of the treatment, the patient experienced difficulty breathing, hypoxia and tachycardia and was found to have bilateral expiratory wheezes. CT angiography showed sub-segmental pulmonary embolus and the patient was transferred to MICU service. The patient was then intubated and started on heparin by the medical team. Over the course of the next day, her respiratory distress resolved and the patient was extubated. It is possible that chlorpromazine may indeed increase VTEs, and there are various physiological postulations regarding the mechanism of action. However, multiple confounding variables existed in the authors' report, including venous stasis and the use of restraints, tobacco and valproic acid. Each of these variables has been shown to increase VTE occurrence. Further controlled studies are necessary to identify the true relationship between antipsychotics and VTEs.
Highlights
Since the development of antipsychotic drugs in the 1950s, a variety of studies and case reports have been published that suggest an association between exposure to typical antipsychotics and venous thromboembolism (VTE)
We describe the development of a pulmonary embolism (PE) associated with use of chlorpromazine in the treatment of an acute manic episode in a patient with a diagnosis of bipolar disorder type 1
It is possible that the 5-HT enhancement is because of elevated plasma noradrenaline in stressed schizophrenics that were concurrently treated with chlorpromazine (Orr and Boullin, 1976) Venous stasis can occur in patients on antipsychotics because of the sedative effects of the drugs
Summary
Since the development of antipsychotic drugs in the 1950s, a variety of studies and case reports have been published that suggest an association between exposure to typical antipsychotics and venous thromboembolism (VTE). Day 2: While in the emergency room, the patient required multiple rounds of emergency medications because of agitation, aggression and inability to redirect from staff on the first night These included two rounds of haloperidol 5 mg 1 lorazepam 2 mg 1 diphenhydramine 50 mg IM, olanzapine 5 mg PO Â 1 and chlorpromazine 50 mg IM Â 1. The CT angiography showed sub-segmental pulmonary embolus and the patient was transferred to MICU service There she was determined to have combined hypercarbic and hypoxic respiratory failure secondary to COPD exacerbation with influenza, possible hospitalacquired pneumonia given prolonged hospital stay and possible PE given immobility in ED, tachycardia and high Well’s score. She was started on heparin by the medical team and over the course of the day, her respiratory distress resolved and she was extubated
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