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Serotonin syndrome (Clinical manifestations (Symptoms (CNS (Encephalopathy…
Serotonin syndrome
Clinical manifestations
Hyperstimulation of 5-HT receptors of brain and spianl cord
Highly variable presentation, spectrum of toxicity
DDx: NMS, MH, dystonic reaction, thyroid storm, CNS infection, cerebral masses, tetanus, heat stress, drug toxicities, lethal catatonia
Symptoms
CNS
Encephalopathy
Hyperreflexia
Autonomic instability
Seizure
CVS: Autonomic instability
GIT: N&V
Renal: Rhabdomyolysis, hyperkalaemia, RF
Haematological: DIC
Other: Hyperpyrexia, sweating
Treatment
Usually self limiting, resolves when offending drug withdrawn - resolve in 24-72hrs
Admit to hospital
Severe forms require supportive therapy
ICU
FLuid and electrolyte
Acid-base mgmt
Renal protection
Haemodynamic support
Active cooling if hypothermia
Neuro support (benzos) - agitation mgmt, seizure mx
Specific mx
Cyproheptadine - serotonin antagonist
Chlorpromazine
Serotonin actions
Central: mood, sleep, vomiting, pain, perception
Peripheral: GI smooth muscle tone, promotes Plt aggregation, inflamm mediator
Risk factors
Drugs that enhance serotonergic neurotransmission or increase synaptic levels of serotonin (initiation or addition of new agent, increased dose)
Serotonin precursor (L-tryptophan)
Inhibit serotonin reuptake
SSRIs e.g. fluoxetine
MAOI (A>B)
TCAs
Tramadol
Increase release and reduce reuptake
Amphetamines, ecstacy, cocaine
Anorectics
Partial serotonin agents
Pethidine
LSD
Buspirone
Other
Atypical antidepressant
ST Johns wort
Lithium