Serotonin syndrome Flashcards

1
Q

Triad of systems affected

A

CNS, autonomic and neuromuscular dysfunction

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2
Q

Causes

A

a. Introduction/increase in dose of a single serotonergic drug
b. Change in therapy from one serotonergic drug to another without adequate washout period
c. Drug interaction between two serotonergic agents
d. Interaction between a serotonergic agent and an illicit drug or herbal preparation
e. Deliberate self-poisoning with serotonergic agents
f. Accidental ingestion of serotonergic agents

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3
Q

Pathogenesis

A

a. Neurotransmitter produced from L-tryptophan
b. Receptors 5-HT1-7
c. Re-uptake from synaptic cleft, metabolised with neurons by MAO (A >B), or stored in vesicles
d. Action of medications
i. ↑ release eg. amphetamines, MDMA
ii. ↓ re-uptake eg. SSRIs, TCAs, dextromethorphan, St Jude’s wort
iii. ↓ metabolism eg. MAOIs
iv. Direct receptor stimulation eg. sumatriptan
v. ↑ production eg. L-tryptophan
vi. Unknown eg. lithium

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4
Q

Neuromuscular effects

A
  • Hyperreflexia
  • Clonus
  • Ocular clonus
  • Myoclonus
  • Shivering
  • Tremor
  • Hypertonia or rigidity
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5
Q

Autonomic effects

A
  • Hyperthermia
  • Diaphoresis
  • Flushing
  • Mydriasis
  • Tachycardia
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6
Q

CNS effects

A
  • Agitation
  • Anxiety
  • Confusion
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7
Q

Associated drugs

A

Antidepressents (MAOIs, TCAs, SSRIs, SNRIs)
Analgesia (Bupropion, Tapentadol, Tramadol, Pethidine, Fentanyl, Dextromethorphan)
Illicits (MDMA, LSD, Amphetamines, Cocaine)
Antiemetics - Ondansetron, Metoclopramide, Sumatriptan Herbals - St John’s Wort, Ginseng, Nutmeg
Other - lithium, appetite suppressants, valproate

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8
Q

Distinguishing effects c/w NMS

A

1) Clonic excitation present (absent in NMS)
2) Lack of EPS symptoms (Parkinsonian features)
3) Presence of autonomic dysfunction

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9
Q

Pharmacotherapy

A

i. Benzodiazepines - rigidity, seizures
ii. Cyproheptadine - serotonin receptor antagonist
iii. Propranolol

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10
Q

SHIVERS

A

S = Shivering
H = Hyperreflexia + myoclonus
I = Increased temperature
V = Vital sign instability
E = Encephalopathy
R = Restlessness
S = Sweating

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