Diferencia entre revisiones de «Serotonin syndrome»
Sin resumen de edición
Línea 1: Línea 1:
==Background==
==Background==
Serotonin works centrally to modulate attention, behavior, thermoregulation
#Can be produced by any serotonergic medication
#Vast majority of cases occur with therapeutic dosages
#Most common cause of death is severe hyperthermia


dx when serotinergic agent/ SSRI recently added to med list
===Causative Agents===
 
===Offending 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
#OTC: Cough meds, herbal products, St John’s Wort
#Triptans
#Triptans
#Bromocriptine
#Bromocriptine
#OTC: Cough meds, herbal products, St John’s Wort
==Clinical Features==
#Altered Mental Status: Agitated delirium
#Autonomic Instability: Hyperthermia, Tachycardia
#Neuromuscular Abnormalities: Myoclonus, ocular clonus, rigidity, Hyperreflexia, tremor
##More pronounced in the lower extremities


==Diagnosis==
==Diagnosis==
===Clinical Triad===
*Hunter Toxicity Criteria Decision Rules
# Altered Mental Status: Agitated delirium
**84% Sn, 97% Sp
# Autonomic Instability: Hyperthermia, Tachycardia
**Serotonergic agent plus 1 of the following:
# Neuromuscular Abnormalities: Clonus, hyperreflexia
#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)


===Physical Exam===
==DDX==
#Clonus is most defining feature: Spontaneous or inducible
#[[Neuroleptic Malignant Syndrome (NMS)]]
#Ocular clonus (horizontal)
#Anticholinergic toxicity
#Shivering
#[[Malignant Hyperthermia]]
#Hyperreflexia
#Sympathomimetic toxicity
#Diaphoresis
#Meningitis/encephalitis
#Nausea
 
===Diagnostic Criteria===
'''Hunter Criteria Decision Rules'''
(84% Sensitivity; 97% Specificity)
 
Serotonergic Agent plus 1 of following:
#Spontaneous Clonus
#Inducible Clonus plus Agitation
#Ocular Clonus plus Agitation
#Clonus plus Hyperthermia
 
OR
 
'''Need 3 of 6'''
# mental status change
# agitation
# myoclonus
# hyperreflexia
# diaphoresis
# shivering
# tremor
# diarrhea
# incoordination
# fever


==Treatment==
==Treatment==
#ABCs
#Discontinue all serotonergic drugs
#Discontinue offending agent
#Benzos
#Supportive Care
##Goal is to eliminate agitation, neuromuscular abnormalities, elevations in HR/BP
#Benzos for agitation
#Avoid physical restraints
#Consider paralysis with non-depolarizing agent
#Cyproheptadine
#Cyproheptadine
#serotonin antagonist (works centrally and peripherally)
##Give if benzos and supportive care fail to improve agitation and abnormal vitals
##Dose: 8mg PO/NG, then 4mg Q2H;
##Serotonin antagonist
##Max 32mg/day
##Give 12mg PO/NG; repeat in 2hr if no initial response (max dose 32mg/d)
 
##Give 4mg q6hr x48hr if pt is responsive to initial dose
==Prognosis==
#Treat hyperthermia
#Generally presents within 6-24H of exposure to offending agent
#Resolves within 24H
#Mortality < 1%


==Source==
==Source==
PANI 6/2009 based on Rosen's 
*Tintinalli
*UpToDate


[[Category:Tox]]
[[Category:Tox]]

Revisión del 11:09 31 dic 2011

Background

  1. Can be produced by any serotonergic medication
  2. Vast majority of cases occur with therapeutic dosages
  3. Most common cause of death is severe hyperthermia

Causative Agents

  1. SSRIs
  2. MAOIs
  3. TCAs
  4. Drugs of Abuse: Cocaine, Ecstasy, Marijuana
  5. Analgesics: Demerol, fentanyl
  6. Antiemetics
  7. Triptans
  8. Bromocriptine
  9. OTC: Cough meds, herbal products, St John’s Wort

Clinical Features

  1. Altered Mental Status: Agitated delirium
  2. Autonomic Instability: Hyperthermia, Tachycardia
  3. Neuromuscular Abnormalities: Myoclonus, ocular clonus, rigidity, Hyperreflexia, tremor
    1. More pronounced in the lower extremities

Diagnosis

  • Hunter Toxicity Criteria Decision Rules
    • 84% Sn, 97% Sp
    • Serotonergic agent plus 1 of the following:
  1. Spontaneous clonus
  2. Inducible clonus AND (agitation or diaphoresis)
  3. Ocular Clonus AND (agitation or diaphoresis)
  4. Tremor AND hyperreflexia
  5. Hypertonia AND temp >38 AND (ocular clonus or inducible clonus)

DDX

  1. Neuroleptic Malignant Syndrome (NMS)
  2. Anticholinergic toxicity
  3. Malignant Hyperthermia
  4. Sympathomimetic toxicity
  5. Meningitis/encephalitis

Treatment

  1. Discontinue all serotonergic drugs
  2. Benzos
    1. Goal is to eliminate agitation, neuromuscular abnormalities, elevations in HR/BP
  3. Cyproheptadine
    1. Give if benzos and supportive care fail to improve agitation and abnormal vitals
    2. Serotonin antagonist
    3. Give 12mg PO/NG; repeat in 2hr if no initial response (max dose 32mg/d)
    4. Give 4mg q6hr x48hr if pt is responsive to initial dose
  4. Treat hyperthermia

Source

  • Tintinalli
  • UpToDate
Obtenido de «https://www.wikem.org/w/index.php?title=Serotonin_syndrome&oldid=7338»