Although they are associated with less toxicity than tricyclic antidepressants (TCAs), co-ingestions with proserotonergic agents, including MAOIs, TCAs, SNRIs, Lithium, Opioids, amphetamine/stimulants can precipitate the potentially lethal serotonin syndrome (SS).
SS represents the most severe end of a spectrum of serotonin excess and is characterized by mental status changes, neuromuscular hyperactivity, and autonomic instability.
Commonly prescribed SSRIs include fluoxetine, sertraline, paroxetine citalopram, escitalopram, and fluvoxamine.
Manifestations
Complications
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Seizures
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Arrhythmia
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Rhabdomyolysis
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Disseminated intravascular coagulation
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Acute renal failure
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Respiratory failure
Clinical management
As with all care in the emergency department, immediate evaluation and stabilization of the patient’s airway, breathing, and circulation is paramount
Treatment is primarily supportive. The initial severity of presentation helps guide appropriate emergency care.
Treat hyperthermia with cooling blankets, fans, ice packs, and IV fluids to prevent development of disseminated intravascular coagulation and multiorgan failure.
Do not administer antipyretics are not indicated because alteration is not caused by a change in the hypothalamic temperature set point but the hyperthermia results from increased muscle activity.
Administer activated charcoal if a potentially lethal amount has been ingested and if the presentation is within 1 to 2 hours.
Treat neuromuscular abnormalities with benzodiazepines.
In severe cases with depressed mental status and vital sign abnormalities, provide airway protection and ventilation if needed. Paralysis and mechanical ventilation (avoid succinylcholine as a paralytic) may be necessary to avoid worsening muscle rigidity and increasing hyperthermia
Hypertension and/or tachycardia requires treatment with short-acting agents such as nitroprusside and esmolol.
