Laboratory Studies

Standard laboratory tests for poisoned patients are indicated if the patient has significant symptoms. Such tests may include the following:

Rapid bedside glucose determination
Arterial blood gas determination - Indicated if a compromise in oxygenation or ventilation is suspected
Lactate level - May be useful in phases 2 and 3 of an acute overdose to help determine end-organ perfusion
Determination of serum electrolyte, calcium, and magnesium levels - Calculation of the anion gap possibly helpful in screening for co-ingestions (see the Anion Gap calculator)
Serum acetaminophen level and salicylate level - Indicated in intentional overdoses
Screening for serum levels of alcohol (ethanol, methanol, isopropyl alcohol) - Indicated if alcohol ingestion is clinically suspected
Urine pregnancy test - Indicated in all women of childbearing age
Urinalysis and urine pH determination - May be useful in the setting of rhabdomyolysis
Urine drug screening - Comprehensive drug screening and screening for commonly abused drugs is possibly helpful in assessing co-ingestions

Quantitative levels of monoamine oxidase inhibitors are not readily available and, therefore, are not clinically useful. Consider workup for hypertensive emergencies if any signs or symptoms are present.

Imaging Studies

Chest radiography is indicated if aspiration is a concern. Perform postintubation chest radiography to evaluate the position of the endotracheal tube in relation to the carina if respiratory support is needed.

Treatment & Management

Affini A, Hagenow S, Zivkovic A, Marco-Contelles J, Stark H. Novel indanone derivatives as MAO B/H₃R dual-targeting ligands for treatment of Parkinson's disease. Eur J Med Chem. 2018 Mar 25. 148:487-497. [QxMD MEDLINE Link].
Woytowish MR, Maynor LM. Clinical relevance of linezolid-associated serotonin toxicity. Ann Pharmacother. 2013 Mar. 47(3):388-97. [QxMD MEDLINE Link].
Manini AF. Monoamine Oxidase Inhibitors. Goldfrank LR, Hoffman RS, Howland MA, Lewin NA, Nelson LS, eds. Goldfrank's Toxicological Emergencies. 10th ed. New York: McGraw-Hill; 2015. 993-1001.
Mills KC. Monoamine oxidase inhibitors. Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. 1203-1207.
Krishnan KR. Revisiting Monoamine Oxidase Inhibitors. J Clin Psychiatry. 2007. 68:35-41. [QxMD MEDLINE Link].
Amsterdam JD. A double-blind, placebo-controlled trial of the safety and efficacy of selegiline transdermal system without dietary restrictions in patients with major depressive disorder. J Clin Psychiatry. 2003 Feb. 64(2):208-14. [QxMD MEDLINE Link].
Preskorn SH. Why the transdermal delivery of selegiline (6 mg/24 hr) obviates the need for a dietary restriction on tyramine. J Psychiatr Pract. 2006 May. 12(3):168-72. [QxMD MEDLINE Link].
Nandagopal JJ, DelBello MP. Selegiline transdermal system: a novel treatment option for major depressive disorder. Expert Opin Pharmacother. 2009 Jul. 10(10):1665-73. [QxMD MEDLINE Link]. [Full Text].
Lerner BH. A Case That Shook Medicine. The Washington Post. November 28, 2006. Available at http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html.
Sansone RA, Sansone LA. Tramadol: seizures, serotonin syndrome, and coadministered antidepressants. Psychiatry (Edgmont). 2009 Apr. 6(4):17-21. [QxMD MEDLINE Link]. [Full Text].
Karkow DC, Kauer JF, Ernst EJ. Incidence of Serotonin Syndrome With Combined Use of Linezolid and Serotonin Reuptake Inhibitors Compared With Linezolid Monotherapy. J Clin Psychopharmacol. 2017 Oct. 37 (5):518-523. [QxMD MEDLINE Link].
Rowley M, Riutort K, Shapiro D, Casler J, Festic E, Freeman WD. Methylene blue-associated serotonin syndrome: a 'green' encephalopathy after parathyroidectomy. Neurocrit Care. 2009. 11(1):88-93. [QxMD MEDLINE Link].
Schwiebert C, Irving C, Gillman PK. Small doses of methylene blue, previously considered safe, can precipitate serotonin toxicity. Anaesthesia. 2009 Aug. 64(8):924. [QxMD MEDLINE Link].
Khavandi A, Whitaker J, Gonna H. Serotonin toxicity precipitated by concomitant use of citalopram and methylene blue. Med J Aust. 2008 Nov 3. 189(9):534-5. [QxMD MEDLINE Link].
Ramsay RR, Dunford C, Gillman PK. Methylene blue and serotonin toxicity:inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction. BR J Pharmocol. 2007/11. 152:946-951.
Delport A, Harvey BH, Petzer A, Petzer JP. The monoamine oxidase inhibition properties of selected structural analogues of methylene blue. Toxicol Appl Pharmacol. 2017 Apr. 325:1-8. [QxMD MEDLINE Link].
Simão AY, Gonçalves J, Duarte AP, Barroso M, Cristóvão AC, Gallardo E. Toxicological Aspects and Determination of the Main Components of Ayahuasca: A Critical Review. Medicines (Basel). 2019 Oct 18. 6 (4):[QxMD MEDLINE Link]. [Full Text].
Gillman PK. Triptans, serotonin agonists, and serotonin syndrome (serotonin toxicity): a review. Headache. 2010 Feb. 50(2):264-72. [QxMD MEDLINE Link].
Litovitz TL, Bailey KM, Schmitz BF, et al. 1990 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. 1991 Sep. 9(5):461-509. [Full Text].
Gummin DD, Mowry JB, Spyker DA, Brooks DE, Beuhler MC, Rivers LJ, et al. 2018 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 36th Annual Report. Clin Toxicol (Phila). 2019 Dec. 57 (12):1220-1413. [QxMD MEDLINE Link]. [Full Text].
Caraci F, Pappalardo G, Basile L, Giuffrida A, Copani A, Tosto R, et al. Neuroprotective effects of the monoamine oxidase inhibitor tranylcypromine and its amide derivatives against Aβ(1-42)-induced toxicity. Eur J Pharmacol. 2015 Oct 5. 764:256-63. [QxMD MEDLINE Link].
Mancini F, Di Fonzo A, Lazzeri G, Borellini L, Silani V, Lacerenza M, et al. Real life evaluation of safinamide effectiveness in Parkinson's disease. Neurol Sci. 2018 Apr. 39 (4):733-739. [QxMD MEDLINE Link].
Pardo JV. Mania following addition of hydroxytryptophan to monoamine oxidase inhibitor. Gen Hosp Psychiatry. 2012 Jan-Feb. 34(1):102.e13-4. [QxMD MEDLINE Link]. [Full Text].
Erich JL, Shih RD, O'Connor RE. "Ping-pong" gaze in severe monoamine oxidase inhibitor toxicity. J Emerg Med. 1995 Sep-Oct. 13(5):653-5. [QxMD MEDLINE Link].
Attaway A, Sroujieh L, Mersfelder TL, Butler C, Ouellette D. "Ping-pong gaze" secondary to monoamine oxidase inhibitor overdose. J Pharmacol Pharmacother. 2016 Jan. 7(1):34-37. [QxMD MEDLINE Link].
Smith JE. Cooling methods used in the treatment of exertional heat illness. Br J Sports Med. 2005 Aug. 39(8):503-7. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Eddie Garcia, MD Resident Physician, Department of Emergency Medicine, Rutgers New Jersey Medical School

Eddie Garcia, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, Emergency Medicine Residents' Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Diane P Calello, MD, FAAP, FACMT, FAACT Executive and Medical Director, New Jersey Poison Information and Education System; Associate Professor, Department of Emergency Medicine, Rutgers New Jersey Medical School; Director of Toxicology, Attending Physician, Pediatric Emergency Department, Morristown Medical Center, Atlantic Health System

Diane P Calello, MD, FAAP, FACMT, FAACT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Attending Physician in Emergency Medicine and Medical Toxicology, Excela Health System

Fred Harchelroad, MD, FACMT, FAAEM, FACEP is a member of the following medical societies: American College of Medical Toxicology

Disclosure: Nothing to disclose.

Chief Editor

Michael A Miller, MD Clinical Professor of Emergency Medicine, Medical Toxicologist, Department of Emergency Medicine, Texas A&M Health Sciences Center; CHRISTUS Spohn Emergency Medicine Residency Program

Michael A Miller, MD is a member of the following medical societies: American College of Medical Toxicology

Disclosure: Nothing to disclose.

Additional Contributors

Richard Lavely, MD, JD, MS, MPH Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine

Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Legal Medicine, American Medical Association

Disclosure: Nothing to disclose.

Steven Marcus, MD Professor, Department of Preventive Medicine and Community Health, Associate Professor, Department of Pediatrics, Rutgers New Jersey Medical School, Rutgers University School of Biomedical and Health Sciences; Executive and Medical Director, New Jersey Poison Information and Education System; Consulting Staff, Departments of Pediatrics and Internal Medicine, University Hospital; Consulting Staff, Department of Pediatrics, Newark Beth Israel Medical Center

Steven Marcus, MD is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Clinical Toxicology, American Academy of Pediatrics, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, Medical Society of New Jersey

Disclosure: Nothing to disclose.

Wirachin Hoonpongsimanont, MD Clinical Instructor, Department of Emergency Medicine, University of California, Irvine

Wirachin Hoonpongsimanont, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.