1. Serotonin Syndrome Case Debrief

2. 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?

3. 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.

4. 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.

5. 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

6. Serotonin Syndrome Signs and symptoms vary by patient (1-2 in each category) –Cognitive-Behavioral –Neuromuscular –Autonomic

7. Serotonin Syndrome Cognitive-Behavioral Signs and Symptoms –Confusion/disorientation –Agitation/irritability –Unresponsiveness –Anxiety –Insomnia –Lethargy –Seizures –Hypomania –Hallucinations –dizziness

8. Serotonin Syndrome Neuromuscular signs and symptoms –Myoclonus –Hyperreflexia –Muscle rigidity –Tremor –Ataxia –Shivering/chills –Nystagmus –Babinski’s sign bilaterally

9. Serotonin Syndrome Autonomic signs and symptoms –Hyperthermia –Diaphoresis –Sinus tachycardia –Hypertension –Tachypnea –Dilated pupils –Non-reactive pupils –Flushed skin –Hypotension –Diarrhea –Abdominal cramps –salivation

10. 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

11. Serotonin Syndrome Differential diagnosis –Serotonin syndrome –Neuroleptic malignant syndrome –Sepsis –Heat stroke –Anticholinergic toxidrome –Thyroid storm

12. References Tintinelli, et al. Emergency Medicine: A Comprehensive Guide. 6 th Edition. http://uuhsc.utah.edu/poison/healthpros/ut ox/vol4_no4.pdfhttp://uuhsc.utah.edu/poison/healthpros/ut ox/vol4_no4.pdf Emedicine.com