Dystonic reaction to haloperidol causing severe tongue swelling requiring cricothyroidotomy

Haloperidol is a widely used drug in both the prehospital setting and the emergency department (ED) for agitation. Though rare, haloperidol can lead to severe dystonic reactions that can cause traumatic tongue swelling. Severe tongue swelling can lead to airway compromise. A 31-year-old female was given haloperidol in the pre-hospital setting by EMS for agitation to allow for transport and medical evaluation. She had a delayed dystonic reaction that led to tongue protrusion, jaw clenching, and subsequent traumatic oral swelling. The severe tongue swelling caused airway compromise requiring an emergency cricothyroidotomy. She recovered in the ICU with removal of airway support on day five. Agitation in patients needing emergency care is not infrequent. Haloperidol is a common medication to treat agitation in both the pre-hospital and emergency department settings. A key to the safe administration of this drug is awareness of life-threatening adverse reactions such as severe dystonic reactions. It is important for emergency providers to be aware that dystonic reactions can cause tongue protrusion, tongue biting, and resultant traumatic tongue swelling. Anti-cholinergic medications are a critical intervention as the first line treatment of dystonia. It is also essential that emergency providers look for medical bracelets prior to giving medications if the patient is unable to communicate allergies. It was discovered in the ED that the patient had a bracelet noting her prior reactions to haloperidol.