Selective Serotonin Reuptake Inhibitor Toxicity Follow-up

  • Author: Tracy A Cushing, MD, MPH, FACEP, FAWM; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Aug 25, 2011
 

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.
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Transfer

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

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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.
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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.
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Contributor Information and Disclosures
Author

Tracy A Cushing, MD, MPH, FACEP, FAWM  Assistant Professor, Department of Emergency Medicine, University of Colorado School of Medicine; Attending Physician, Denver Health Medical Center

Tracy A Cushing, MD, MPH, FACEP, FAWM 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.

Specialty Editor Board

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT  Associate Clinical Professor, Department of Surgery/Emergency Medicine and Toxicology, University of Texas School of Medicine at San Antonio; Medical and Managing Director, South Texas Poison Center

Miguel C Fernandez, 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

John G Benitez, MD, MPH  Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, 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.

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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