eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Selective Serotonin Reuptake Inhibitor: Follow-up

Author: Tracy A Cushing, MD, MPH, Instructor in Medicine, Department of Emergency Medicine, Harvard Medical School; Attending Physician, Department of Emergency Medicine, Mount Auburn Hospital
Coauthor(s): Theodore I Benzer, MD, PhD, Assistant Professor in Medicine, Harvard Medical School; Director of Clinical Operations, Director of Toxicology, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Oct 22, 2009

Follow-up

Further Inpatient Care

  • All patients with significant ingestions requiring intubation or vasopressors or those with a temperature higher than 40ºC or ECG changes/dysrhythmias should be admitted to an intensive care unit. Moderate toxicity can be safely observed in the hospital for 24 hours, and mild cases can be safely discharged (if asymptomatic) from the emergency department once cleared by psychiatry in cases of intentional overdose and after 6-8 hours of observation.
  • Inpatient care should include ongoing fluid resuscitation, appropriate treatment of rhabdomyolysis, DIC, and renal or hepatic dysfunction, as well as psychiatric evaluation.

Transfer

  • Transfer any patient who requires a level of care that is not available (eg, an intensive care unit).

Deterrence/Prevention

  • Patients taking SSRIs and MAOIs should be cautioned about taking over-the-counter medications or supplements with serotonergic activity. They should be closely monitored if dosages are adjusted or medications are added to their regimen.

Complications

Prognosis

  • Most cases will fully resolve without residual deficits if supportive care has been provided. The prognosis is generally favorable.
  • Most fatalities occur within the first 24 hours.
  • Patients who remain asymptomatic for 6-8 hours after ingestion are unlikely to require further treatment.

Patient Education

  • Patients should be counseled about potential interactions among any medications they take and over-the-counter drugs and so-called herbal supplements that may precipitate SS. They should be restarted on, or introduced to, serotonergic medications very gradually in the future (after "wash-out" period). They should report this reaction to all health care providers in the future.
  • All patients started on SSRIs by psychiatrists or primary care physicians should be educated about symptoms of serotonin toxicity and SS.
  • A minimum of 2 weeks should elapse between termination of an SSRI or MAOI and initiation of a new one. Drugs with a longer half-life (ie, fluoxetine) require up to 5 weeks of wash-out. Elderly patients and those taking liver MFOs may require an extended wash-out period as well.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose SS and institute proper treatment
  • Failure to obtain a complete history of a patient's medications, resulting in prescribing serotonergic medications to patients already taking SSRIs or MAOIs
  • Failure to counsel patients with regard to over-the-counter medications (particularly dextromethorphan-containing cold remedies), illicit drugs (especially amphetamines, MDMA, cocaine, and mescaline), and herbal dietary supplements/nutraceuticals (eg, St. John's wort, ginseng, and S-adenosyl-methionine) that might affect the patient's tissue concentrations of serotonin
  • Symptomatic patients with citalopram/escitalopram overdose may require admission to the monitored bed for 24 hours because of the risk of delayed toxicity that can cause prolonged QTc interval and consequent cardiac dysrhythmias (eg, torsades de pointes).
 


More on Toxicity, Selective Serotonin Reuptake Inhibitor

Overview: Toxicity, Selective Serotonin Reuptake Inhibitor
Differential Diagnoses & Workup: Toxicity, Selective Serotonin Reuptake Inhibitor
Treatment & Medication: Toxicity, Selective Serotonin Reuptake Inhibitor
Follow-up: Toxicity, Selective Serotonin Reuptake Inhibitor
References
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References

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Further Reading

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Keywords

selective serotonin reuptake inhibitor toxicity, SSRIs, SSRI overdose, serotonin syndrome, SS, SSRI toxicity, fluoxetine, Prozac, sertraline, Zoloft, paroxetine, Paxil, citalopram, Celexa, escitalopram, Lexapro, fluvoxamine, Luvox, SSRI toxicity, serotonin overdose, serotonin syndrome, SS, 5-hydroxytryptamine, 5HT

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Contributor Information and Disclosures

Author

Tracy A Cushing, MD, MPH, Instructor in Medicine, Department of Emergency Medicine, Harvard Medical School; Attending Physician, Department of Emergency Medicine, Mount Auburn Hospital
Tracy A Cushing, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Theodore I Benzer, MD, PhD, Assistant Professor in Medicine, Harvard Medical School; Director of Clinical Operations, Director of Toxicology, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital
Theodore I Benzer, MD, PhD is a member of the following medical societies: Alpha Omega Alpha and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Miguel C Fernández, MD, FAAEM, FACEP, FACMT, FACCT, Associate Clinical Professor; Medical and Managing Director, South Texas Poison Center, Department of Surgery/Emergency Medicine and Toxicology, University of Texas Health Science Center at San Antonio
Miguel C Fernández, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Clinical Toxicologists, American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, Society for Academic Emergency Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

John G Benitez, MD, MPH, FACMT, FACPM, FAAEM, Associate Professor, Department of Medicine, Clinical Pharmacology Division, Vanderbilt University; Managing Director, Tennessee Poison Center
John G Benitez, MD, MPH, FACMT, FACPM, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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