Serotonin syndrome: Difference between revisions
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===Causative Agents=== | ===Causative Agents=== | ||
*[[SSRIs]] | |||
*MAOIs | |||
*TCAs | |||
*Drugs of Abuse: Cocaine, Ecstasy, Marijuana | |||
*Analgesics: Demerol, fentanyl | |||
*Antiemetics | |||
*Triptans | |||
*Bromocriptine | |||
*OTC: Cough meds, herbal products, St John’s Wort | |||
==Clinical Features== | ==Clinical Features== | ||
*Altered Mental Status: Agitated delirium | |||
*Autonomic Instability: Hyperthermia, Tachycardia, diaphoresis | |||
*Neuromuscular Abnormalities: Myoclonus, ocular clonus, rigidity, hyperreflexia, tremor | |||
**More pronounced in the lower extremities | |||
**Myoclonus: most common finding | |||
***Important to identify because it does not occur in other conditions that mimic serotonin syndrome | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Line 35: | Line 35: | ||
*84% Sn, 97% Sp | *84% Sn, 97% Sp | ||
*Serotonergic agent plus 1 of the following: | *Serotonergic agent plus 1 of the following: | ||
*Spontaneous clonus | |||
*Inducible clonus AND (agitation or diaphoresis) | |||
*Ocular Clonus AND (agitation or diaphoresis) | |||
*Tremor AND hyperreflexia | |||
*Hypertonia AND temp >38 AND (ocular clonus or inducible clonus) | |||
==Treatment== | ==Treatment== | ||
#Discontinue all serotonergic drugs | #Discontinue all serotonergic drugs | ||
#Benzos | #Benzos | ||
# | #*Goal is to eliminate agitation, neuromuscular abnormalities, elevations in HR/BP | ||
#Cyproheptadine | #Cyproheptadine | ||
# | #*Give if benzos and supportive care fail to improve agitation and abnormal vitals | ||
# | #*Serotonin antagonist | ||
# | #*Give 12mg PO/NG; repeat with 2mg q2hr until clinical response is seen (max 32mg/d) | ||
# | #*Give 4mg q6hr x48hr if pt is responsive to initial dose | ||
#Treat hyperthermia | #Treat hyperthermia | ||
# | #*Hyperthermia due to increase in muscular activity, not change in set point | ||
# | #*[[Intubate]] and paralyze | ||
# | #*Standard [[cooling measures]] | ||
==Disposition== | ==Disposition== | ||
==See Also== | ==See Also== | ||
[[Toxidromes]] | *[[Toxidromes]] | ||
==References== | ==References== | ||
[[Category:Tox]] | [[Category:Tox]] |
Revision as of 15:39, 10 June 2015
Background
- Can be produced by any serotonergic medication
- Vast majority of cases occur with therapeutic dosages
- Most common cause of death is severe hyperthermia
Causative Agents
- SSRIs
- MAOIs
- TCAs
- Drugs of Abuse: Cocaine, Ecstasy, Marijuana
- Analgesics: Demerol, fentanyl
- Antiemetics
- Triptans
- Bromocriptine
- OTC: Cough meds, herbal products, St John’s Wort
Clinical Features
- Altered Mental Status: Agitated delirium
- Autonomic Instability: Hyperthermia, Tachycardia, diaphoresis
- Neuromuscular Abnormalities: Myoclonus, ocular clonus, rigidity, hyperreflexia, tremor
- More pronounced in the lower extremities
- Myoclonus: most common finding
- Important to identify because it does not occur in other conditions that mimic serotonin syndrome
Differential Diagnosis
- Neuroleptic Malignant Syndrome (NMS)
- Anticholinergic Toxicity
- Malignant Hyperthermia
- Sympathomimetic toxicity
- Meningitis
- Encephalitis
Diagnosis
Hunter Toxicity Criteria Decision Rules
- 84% Sn, 97% Sp
- Serotonergic agent plus 1 of the following:
- Spontaneous clonus
- Inducible clonus AND (agitation or diaphoresis)
- Ocular Clonus AND (agitation or diaphoresis)
- Tremor AND hyperreflexia
- Hypertonia AND temp >38 AND (ocular clonus or inducible clonus)
Treatment
- Discontinue all serotonergic drugs
- Benzos
- Goal is to eliminate agitation, neuromuscular abnormalities, elevations in HR/BP
- Cyproheptadine
- Give if benzos and supportive care fail to improve agitation and abnormal vitals
- Serotonin antagonist
- Give 12mg PO/NG; repeat with 2mg q2hr until clinical response is seen (max 32mg/d)
- Give 4mg q6hr x48hr if pt is responsive to initial dose
- Treat hyperthermia
- Hyperthermia due to increase in muscular activity, not change in set point
- Intubate and paralyze
- Standard cooling measures