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==Background==
==Background==
Serotonin works centrally to modulate attention, behavior, thermoregulation
Serotonin works centrally to modulate attention, behavior, thermoregulation
== ==


dx when serotinergic agent/ SSRI recently added to med list
dx when serotinergic agent/ SSRI recently added to med list


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


==Diagnosis==
==Diagnosis==
===Clinical Triad===
# Altered Mental Status: Agitated delirium
# Autonomic Instability: Hyperthermia, Tachycardia
# Neuromuscular Abnormalities: Clonus, hyperreflexia


===Physical Exam===
#Clonus is most defining feature: Spontaneous or inducible
#Ocular clonus (horizontal)
#Shivering
#Hyperreflexia
#Diaphoresis
#Nausea


Clinical Triad:
===Diagnostic Criteria===
 
'''Hunter Criteria Decision Rules'''
1) Altered Mental Status: Agitated delirium
 
2) Autonomic Instability: Hyperthermia, Tachycardia
 
3) Neuromuscular Abnormalities: Clonus, hyperreflexia
 
 
Physical Exam
 
Clonus is most defining feature: Spontaneous or inducible
 
Ocular clonus (horizontal)
 
Shivering
 
Hyperreflexia
 
Diaphoresis
 
Nausea
 
 
Diagnostic Criteria
 
Hunter Criteria Decision Rules
 
(84% Sensitivity; 97% Specificity)
(84% Sensitivity; 97% Specificity)


Serotonergic Agent plus 1 of following:
Serotonergic Agent plus 1 of following:
 
#Spontaneous Clonus
Spontaneous Clonus
#Inducible Clonus plus Agitation
 
#Ocular Clonus plus Agitation
Inducible Clonus plus Agitation
#Clonus plus Hyperthermia
 
Ocular Clonus plus Agitation
 
Clonus plus Hyperthermia
 
 


OR
OR


need 3 of 6
need 3 of 6
 
# mental status change
- mental status change
# agitation
 
# myoclonus
- agitation
# hyperreflexia
 
# diaphoresis
- myoclonus
# shivering
 
# tremor
- hyperreflexia
# diarrhea
 
# incoordination
- diaphoresis
# fever
 
- shivering
 
- tremor
 
- diarrhea
 
- incoordination
 
- fever
 


==Treatment==
==Treatment==
 
#ABCs
 
#Discontinue offending agent
ABCs
#Supportive Care
 
#Benzos for agitation
Discontinue offending agent
#Avoid physical restraints
 
#Consider paralysis with non-depolarizing agent
Supportive Care
#Cyproheptadine
 
#serotonin antagonist (works centrally and peripherally)
Benzos for agitation
 
Avoid physical restraints
 
Consider paralysis with non-depolarizing agent
 
Cyproheptadine
 
serotonin antagonist (works centrally and peripherally)


An animal model showed that an initial dose (12mg) blocked 85-95% of serotonin receptors
An animal model showed that an initial dose (12mg) blocked 85-95% of serotonin receptors
Línea 138: Línea 74:


Mortality < 1%
Mortality < 1%


==Source==
==Source==
PANI 6/2009 based on Rosen's   
PANI 6/2009 based on Rosen's   


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

Revisión del 05:52 13 jun 2011

Background

Serotonin works centrally to modulate attention, behavior, thermoregulation

dx when serotinergic agent/ SSRI recently added to med list

Offending Agents

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

Diagnosis

Clinical Triad

  1. Altered Mental Status: Agitated delirium
  2. Autonomic Instability: Hyperthermia, Tachycardia
  3. Neuromuscular Abnormalities: Clonus, hyperreflexia

Physical Exam

  1. Clonus is most defining feature: Spontaneous or inducible
  2. Ocular clonus (horizontal)
  3. Shivering
  4. Hyperreflexia
  5. Diaphoresis
  6. Nausea

Diagnostic Criteria

Hunter Criteria Decision Rules (84% Sensitivity; 97% Specificity)

Serotonergic Agent plus 1 of following:

  1. Spontaneous Clonus
  2. Inducible Clonus plus Agitation
  3. Ocular Clonus plus Agitation
  4. Clonus plus Hyperthermia

OR

need 3 of 6

  1. mental status change
  2. agitation
  3. myoclonus
  4. hyperreflexia
  5. diaphoresis
  6. shivering
  7. tremor
  8. diarrhea
  9. incoordination
  10. fever

Treatment

  1. ABCs
  2. Discontinue offending agent
  3. Supportive Care
  4. Benzos for agitation
  5. Avoid physical restraints
  6. Consider paralysis with non-depolarizing agent
  7. Cyproheptadine
  8. serotonin antagonist (works centrally and peripherally)

An animal model showed that an initial dose (12mg) blocked 85-95% of serotonin receptors

Dose: 8mg PO/NG, then 4mg Q2H;

Max 32mg/day

Clinical Course

Serotonin Syndrome generally presents within 6-24H of exposure to offending agent Resolves within 24H

Mortality < 1%

Source

PANI 6/2009 based on Rosen's

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