Serotonin syndrome: Difference between revisions

No edit summary
No edit summary
Line 5: Line 5:


===Causative Agents===
===Causative Agents===
#[[SSRIs]]
*[[SSRIs]]
#MAOIs
*MAOIs
#TCAs
*TCAs
#Drugs of Abuse: Cocaine, Ecstasy, Marijuana
*Drugs of Abuse: Cocaine, Ecstasy, Marijuana
#Analgesics: Demerol, fentanyl
*Analgesics: Demerol, fentanyl
#Antiemetics
*Antiemetics
#Triptans
*Triptans
#Bromocriptine
*Bromocriptine
#OTC: Cough meds, herbal products, St John’s Wort
*OTC: Cough meds, herbal products, St John’s Wort


==Clinical Features==
==Clinical Features==
#Altered Mental Status: Agitated delirium
*Altered Mental Status: Agitated delirium
#Autonomic Instability: Hyperthermia, Tachycardia, diaphoresis
*Autonomic Instability: Hyperthermia, Tachycardia, diaphoresis
#Neuromuscular Abnormalities: Myoclonus, ocular clonus, rigidity, hyperreflexia, tremor
*Neuromuscular Abnormalities: Myoclonus, ocular clonus, rigidity, hyperreflexia, tremor
##More pronounced in the lower extremities
**More pronounced in the lower extremities
##Myoclonus: most common finding
**Myoclonus: most common finding
###Important to identify because it does not occur in other conditions that mimic serotonin syndrome
***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
*Spontaneous clonus
#Inducible clonus AND (agitation or diaphoresis)
*Inducible clonus AND (agitation or diaphoresis)
#Ocular Clonus AND (agitation or diaphoresis)
*Ocular Clonus AND (agitation or diaphoresis)
#Tremor AND hyperreflexia
*Tremor AND hyperreflexia
#Hypertonia AND temp >38 AND (ocular clonus or inducible clonus)
*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
#*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
#*Give if benzos and supportive care fail to improve agitation and abnormal vitals
##Serotonin antagonist
#*Serotonin antagonist
##Give 12mg PO/NG; repeat with 2mg q2hr until clinical response is seen (max 32mg/d)
#*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
#*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
#*Hyperthermia due to increase in muscular activity, not change in set point
##Intubate and paralyze
#*[[Intubate]] and paralyze
##Standard cooling measures
#*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

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

  1. Discontinue all serotonergic drugs
  2. Benzos
    • Goal is to eliminate agitation, neuromuscular abnormalities, elevations in HR/BP
  3. 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
  4. Treat hyperthermia
    • Hyperthermia due to increase in muscular activity, not change in set point
    • Intubate and paralyze
    • Standard cooling measures

Disposition

See Also

References