Selective Serotonin Reuptake Inhibitor Toxicity Treatment & Management

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

Prehospital Care

Prehospital care includes airway management and arrhythmia treatment per ACLS protocols; consider naloxone 2 mg IV, 50 mL of D50W, and thiamine 100 mg IV as well as a fingerstick glucose level for altered mental status. Of prime importance is getting history from any bystanders or family members and collecting ancillary materials, such as pills, empty pill bottles or medication packets, and suicide notes. If given, naloxone should be gradually titrated starting with 0.05 or 0.1 mg, and repeated if needed, to avoid rapid precipitation of opioid withdrawal.

Out-of-hospital management guidelines are available from the American Association of Poison Control Centers.[21]

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Emergency Department Care

As for all care in the emergency department, the patient needs immediate evaluation and stabilization of the airway, breathing, and circulation, even without knowledge of the ultimate diagnosis. Treatment of serotonin syndrome is primarily supportive. The severity of presentation helps to guide appropriate emergency department care.

  • Mild cases: Check laboratory results as indicated, intravenous fluids, benzodiazepines for agitation/restlessness, avoidance of all serotonergic medications.
  • Moderate cases: Treat hyperthermia with cooling blankets, fans, ice packs, and intravenous fluids. The role for antipyretics is limited, as the mechanism of temperature alteration is centrally mediated. Administer activated charcoal if a potentially lethal amount has been ingested and if presentation is within 1-2 hours. Treat neuromuscular abnormalities with benzodiazepines.
  • Severe cases: Patients with hyperthermia, depressed mental status, and vital sign abnormalities should be treated aggressively. All patients should be treated as above, with the addition of airway protection and ventilation if needed. Paralysis and mechanical ventilation may be necessary to avoid worsening muscle rigidity and increasing hyperthermia in any patient with a temperature higher than 41ºC. Patients with severe hyperthermia that is unresponsive to aforementioned measures should be immersed into an ice bath if feasible to achieve rapid cooling and to prevent development of DIC and multiorgan failure (MOF). Avoid succinylcholine as a paralytic in any patient with possible rhabdomyolysis to prevent development of hyperkalemia.
  • Severely ill patients could be treated pharmacologically with 5HT antagonists, such as cyproheptadine[22] (see dosing information below). Efficacy has not been established in randomized clinical trials; however, it has shown benefit in animal models and case reports. It is available only in oral form, which can be crushed and infused via nasogastric tube. Caution should be exercised in hyperthermic patients, because cyproheptadine has anticholinergic properties and theoretically can worsen hyperthermia.
  • Autonomic instability requires treatment with short-acting agents that are amenable to titration, such as nitroprusside and esmolol.
  • Treat rhabdomyolysis with aggressive hydration, and alkalinize urine with sodium bicarbonate for renal protection.[23]
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Consultations

  • Medical toxicologist
  • Poison Control Center at (800) 222-1222 (US and territories only)
  • Psychiatrist
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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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