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
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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
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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/ut
ox/vol4_no4.pdf
• Emedicine.com