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Serotonin Syndrome Case Debrief
Case Debriefing
• How do you think that the case went overall?
• What was done well by the team leader? by the participants?
• How did you come to a concrete diagnosis?
• What factors played a role in the patient’s disposition?
• What could have been done better?
Serotonin Syndrome
• First described in 1959 in TB patients.
• Named in 1982 to describe the symptoms that occur when >2 drugs that increase serotonin concentrations are given.
Serotonin Syndrome
• Pathophysiology– Hyperserotonergic state caused by excessive
stimulation of the serotonin 5HT1A receptors– Different types of serotonin receptors are
found throughout the organ systems in the body.
Serotonin Syndrome
• Drugs that increase serotonin– Precursor – L-tryptophan– Inhibit serotonin metabolism – MAOIs– Increase serotonin release – amphetamines,
lithium, MDMA– Inhibit serotonin reuptake – cocaine,
dextromephoraphan, meperidine, SSRIs, TCAs, trazadone, venlafaxine
– Serotonin receptor agonists – buspirone, LSD– Dopamine agonists – l-dopa
Serotonin Syndrome
• Signs and symptoms vary by patient (1-2 in each category)– Cognitive-Behavioral– Neuromuscular– Autonomic
Serotonin Syndrome
• Cognitive-Behavioral Signs and Symptoms– Confusion/disorientation– Agitation/irritability– Unresponsiveness– Anxiety– Insomnia– Lethargy– Seizures– Hypomania– Hallucinations– dizziness
Serotonin Syndrome
• Neuromuscular signs and symptoms– Myoclonus– Hyperreflexia– Muscle rigidity– Tremor– Ataxia– Shivering/chills– Nystagmus– Babinski’s sign bilaterally
Serotonin Syndrome
• Autonomic signs and symptoms– Hyperthermia– Diaphoresis– Sinus tachycardia– Hypertension– Tachypnea– Dilated pupils– Non-reactive pupils– Flushed skin– Hypotension– Diarrhea– Abdominal cramps– salivation
Serotonin syndrome
• Clinically– Vital signs abnormally high – Temperature, Pulse,
Respiratory Rate, Blood Pressure– Symptoms as previously discussed
• Treatment– Supportive with aggressive cooling measures– Benzodiazepines for seizures, rigidity, agitation– Cyproheptadine for severe cases (PO form only)
• Precautions– Cardiovascular collapse– Seizures
Serotonin Syndrome
• Differential diagnosis– Serotonin syndrome– Neuroleptic malignant syndrome– Sepsis– Heat stroke– Anticholinergic toxidrome– Thyroid storm
References
• Tintinelli, et al. Emergency Medicine: A Comprehensive Guide. 6th Edition.
• http://uuhsc.utah.edu/poison/healthpros/utox/vol4_no4.pdf
• Emedicine.com