Selective serotonin reuptake inhibitor toxicity - Revision history

Danbot: Add MedicationDose entry for magnesium sulfate

2026-03-20T21:12:57Z

Add MedicationDose entry for magnesium sulfate

@@ Línea 65: / Línea 65: @@
 *Consider admission for patients who are tachycardic or lethargic 6hr after ingestion
 *ECG before clearing a patient with citalopram ingestion
 ==See Also==

Rossdonaldson1: /* Management */

2022-07-06T21:21:50Z

Management

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	==Management==		==Management==
	*Supportive care		*Treatment is mostly supportive. Consult poison control for guidance, if needed.
	*No role for [[activated charcoal]] or gastric lavage		*Administer [[activated charcoal]] if lethal amount ingested within 1-2 hours
	*[[Magnesium]] sulfate 2g IV if QTc > 500 msec		*Continuous cardiac monitoring required for citalopram (>600 mg) and escitalopram (>300mg) for at least 8 hours.
	*IV [[benzodiazepines]] if agitation or seizures		**If citalopram (>1000 mg) and escitalopram (>500 mg) has been ingested then monitor for 12-24 hours
			***[[Magnesium]] sulfate 2g IV if QTc > 500 msec
			*Manage [[seizures]] with [[benzodiazepines]]
			*Manage [[hyperthermia]]


	*Treatment is mostly supportive. Consult poison control for guidance
	*Administer activated charcoal if lethal amount ingested within 1-2 hours
	*Continuous cardiac monitoring required for citalopram (>600 mg) and escitalopram (>300mg) for at least 8 hours. If citalopram (>1000 mg) and escitalopram (>500 mg) has been ingested then monitor for 12-24 hours
	*Manage seizures w/ benzodiazepines
	*Manage hyperthermia
	*If suspecting [[Serotonin Syndrome]], stop all serotonergic medication:		*If suspecting [[Serotonin Syndrome]], stop all serotonergic medication:
	**SSRIs		**SSRIs

Rossdonaldson1: /* Workup */

2022-07-06T21:19:08Z

Workup

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	==Evaluation==		==Evaluation==
	===Workup===		===Workup===
			*[[ECG]]
			**QRS, [[QT prolongation]] (citalopram only)

	===Diagnosis===		===Diagnosis===

Rossdonaldson1: /* Clinical Features */

2022-07-06T21:18:35Z

Clinical Features

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	***[[Hyperthermia]]		***[[Hyperthermia]]
	***[[Hypertension]]/[[hypotension]]		***[[Hypertension]]/[[hypotension]]
			***[[Sinus tachycardia]]
	**Neuromuscular hyperactivity		**Neuromuscular hyperactivity
	***Hyperreflexia		***Hyperreflexia
	***Muscular rigidity		***Muscular rigidity
	***Resting tremor		***Resting tremor

	*[[Sinus tachycardia]]
	*QRS, [[QT prolongation]] (citalopram only)

	==Differential Diagnosis==		==Differential Diagnosis==

Rossdonaldson1: /* Background */

2022-07-06T21:17:42Z

Background

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	==Background==		==Background==
	*Most serious adverse effect is potential to produce [[serotonin ~~Syndrome~~]]		*Most serious adverse effect is potential to produce [[serotonin syndrome]]
	*~~Fatalities~~ are uncommon with ~~pure overdoses~~		**However, serotonin syndrome unlikely to occur unless co-ingested with other serotonergic drug classes (MAOIs, SNRI, TCAs, amphetamines, opiates)
	*~~Selective serotonin reuptake inhibitors (SSRI) are~~ the most commonly prescribed antidepressants in the United States<ref>Pirraglia PA, Stafford RS, Singer DE. Trends in Prescribing of Selective Serotonin Reuptake Inhibitors and Other Newer Antidepressant Agents in Adult Primary Care. Prim Care Companion J Clin Psychiatry. 2003 Aug;5(4):153-157. doi: 10.4088/pcc.v05n0402. PMID: 15213776; PMCID: PMC419384.</ref>		*Pure overdoses are generally benign (mortality uncommon). Associated with less toxicity than tricyclic antidepressants.
			*Are the most commonly prescribed antidepressants in the United States<ref>Pirraglia PA, Stafford RS, Singer DE. Trends in Prescribing of Selective Serotonin Reuptake Inhibitors and Other Newer Antidepressant Agents in Adult Primary Care. Prim Care Companion J Clin Psychiatry. 2003 Aug;5(4):153-157. doi: 10.4088/pcc.v05n0402. PMID: 15213776; PMCID: PMC419384.</ref>
	*Examples include fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox), sertraline (Zoloft), escitalopram (Lexapro), and citalopram (Celexa)		*Examples include fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox), sertraline (Zoloft), escitalopram (Lexapro), and citalopram (Celexa)
	*Overdose is generally benign. Associated with less toxicity than tricyclic antidepressants		*Citalopram (>600 mg) and escitalopram (>300mg) are unique, as they may cause dose dependent [[QT prolongation]] and increase risk of [[torsades de pointes]]
	*Serotonin syndrome unlikely to occur unless co-ingested with other serotonergic drug classes (MAOIs, SNRI, TCAs, amphetamines, opiates)
	*Citalopram (>600 mg) and escitalopram (>300mg) are unique, as they may cause dose dependent QT prolongation and increase risk of torsades de pointes

	==Clinical Features==		==Clinical Features==

Rossdonaldson1: /* Clinical Features */

2022-07-06T20:09:22Z

Clinical Features

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	==Clinical Features==		==Clinical Features==
	*[[Nausea and vomiting]]
	*Sedation
	*Tremor
	*[[Sinus tachycardia]]
	*QRS, [[QT prolongation]] (citalopram only)
	*[[Serotonin syndrome]]
	*[[Coma]] and [[seizures]] (rare)






	*'''Symptoms'''		*'''Symptoms'''
	**Nausea/vomiting		**[[Nausea and vomiting]]
	**Agitation		**[[Agitation]]
	**Ataxia		**[[Ataxia]]
	**Confusion		**[[Confusion]]
	*'''Signs'''		*'''Signs'''
	**Altered mental status		**[[Altered mental status]]
	**Autonomic instability		**Autonomic instability
	***Diaphoresis		***Diaphoresis
	***Hyperthermia		***[[Hyperthermia]]
	***Hypertension/hypotension		***[[Hypertension]]/[[hypotension]]
	**Neuromuscular hyperactivity		**Neuromuscular hyperactivity
	***Hyperreflexia		***Hyperreflexia
	***Muscular rigidity		***Muscular rigidity
	***Resting tremor		***Resting tremor

			*[[Sinus tachycardia]]
			*QRS, [[QT prolongation]] (citalopram only)

	==Differential Diagnosis==		==Differential Diagnosis==

Rossdonaldson1: /* Management */

2022-07-06T20:07:04Z

Management

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	*IV [[benzodiazepines]] if agitation or seizures		*IV [[benzodiazepines]] if agitation or seizures

	~~==Management==~~



	*Treatment is mostly supportive. Consult poison control for guidance		*Treatment is mostly supportive. Consult poison control for guidance
	*Administer activated charcoal if lethal amount ingested within 1-2 hours		*Administer activated charcoal if lethal amount ingested within 1-2 hours
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	**Analgesics (fentanyl, tramadol, methadone)		**Analgesics (fentanyl, tramadol, methadone)
	**Antibiotics (linezolid)		**Antibiotics (linezolid)


	==Disposition==		==Disposition==

Rossdonaldson1: /* Clinical Features */

2022-07-06T20:06:37Z

Clinical Features

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	~~==Clinical Features==~~



	*'''Symptoms'''		*'''Symptoms'''
	**Nausea/vomiting		**Nausea/vomiting

Rossdonaldson1: /* Differential Diagnosis */

2022-07-06T20:05:31Z

Differential Diagnosis

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	==Differential Diagnosis==		==Differential Diagnosis==
	*[[Serotonin syndrome]]		*[[Serotonin syndrome]]
	~~{{Anticholinergic types}}~~







	*[[Neuroleptic Malignant Syndrome]]		*[[Neuroleptic Malignant Syndrome]]
	*[[Acetaminophen Toxicity]]		*[[Acetaminophen Toxicity]]
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	*[[Rhabdomyolysis]]		*[[Rhabdomyolysis]]
	*[[Tetanus]]		*[[Tetanus]]

			{{Anticholinergic types}}

	==Evaluation==		==Evaluation==

Rossdonaldson1: /* Differential Diagnosis */

2022-07-06T20:05:04Z

Differential Diagnosis

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	~~==Differential Diagnosis==~~



	*[[Neuroleptic Malignant Syndrome]]		*[[Neuroleptic Malignant Syndrome]]
	*[[Acetaminophen Toxicity]]		*[[Acetaminophen Toxicity]]
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	*[[Rhabdomyolysis]]		*[[Rhabdomyolysis]]
	*[[Tetanus]]		*[[Tetanus]]


	==Evaluation==		==Evaluation==