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