eMedicine Specialties > Emergency Medicine > Toxicology
Toxicity, Selective Serotonin Reuptake Inhibitor: Follow-up
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
- Seizures
- Aspiration pneumonia
- Rhabdomyolysis
- Disseminated intravascular coagulation
- Acute renal failure
- Respiratory failure
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).
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References
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Further Reading
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
Follow-up: Toxicity, Selective Serotonin Reuptake Inhibitor