Serotonin syndrome is a potentially life-threatening disease, which is caused by an increased serotonergic activity of the CNS, which is usually in conjunction with medication. Symptoms may include mental status changes, hyperthermia, and autonomic and neuromuscular hyperactivity. The diagnosis is made clinically. Treatment is supportive.
The serotonin syndrome may in the course of a therapeutic medication, self-poisoning, or, most commonly occur through accidental drug interactions when two serotonergic drugs to be taken (drugs that can cause serotonin syndrome). It can occur in all age groups.
Serotonin syndrome is a potentially life-threatening disease, which is caused by an increased serotonergic activity of the CNS, which is usually in conjunction with medication. Symptoms may include mental status changes, hyperthermia, and autonomic and neuromuscular hyperactivity. The diagnosis is made clinically. Treatment is supportive. The serotonin syndrome may in the course of a therapeutic medication, self-poisoning, or, most commonly occur through accidental drug interactions when two serotonergic drugs to be taken (drugs that can cause serotonin syndrome). It can occur in all age groups. Complications of severe serotonin syndrome may be metabolic acidosis, rhabdomyolysis, seizures, acute kidney injury and disseminated intravascular coagulation (DIC). Causes are likely to produce severe hyperthermia and excessive muscle activity. Drugs that can cause serotonin syndrome class drugs antidepressants: monoamine oxidase inhibitors phenelzine isocarboxazid, linezolid, selegiline, tranylcypromine antidepressants: serotonin norepinephrine reuptake inhibitor bupropion, nefazodone trazodone, venlafaxine Antidepressants: SSRI citalopram escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline Antidepressants: tricyclic antidepressants amitriptyline amoxapine, desipramine doxepin imipramine maprotiline nortriptyline protriptyline trimipramine CNS stimulants amphetamine cocaine diethylpropion methamphetamine 3,4-Methylenedioxyamphetamine (MDA) 3,4-methylenedioxymethamphetamine (MDMA or ecstasy) methylphenidate phentermine, sibutramine hallucinogens lysergic acid diethylamide (LSD) of 5-methoxy Diisopropyltryptamin herbs nutmeg Panax (Asian or American) ginseng St. John Syrian Weinraute 5-hydroxytryptamine (5 -HT1) agonists (triptan) eletriptan, almotriptan frovatriptan naratriptan rizatriptan sumatriptan zolmitriptan opioids, buprenorphine, fentanyl, hydrocodone meperidine oxycodone pentazocine Pethidi Tramadol More buspirone chlorpheniramine, dextromethorphan granisetron 5-hydroxytryptophan levodopa lithium metoclopramide, ondansetron, risperidone, olanzapine ritonavir tryptophan valproate Serotonin syndrome symptoms and discomfort in most cases manifests itself within 24 hours and usually occurs within 6 h when changing the dose or the introduction of a drug. Manifestations can vary greatly in severity. They can be divided into the following categories: changes in mental state: anxiety, agitation and restlessness, rapid alarmed Delirium Autonomous hyperactivity: tachycardia, hypertension, hyperthermia, sweating, chills, vomiting, diarrhea Neuromuscular hyperactivity: tremor, muscle hypertension or rigidity, myoclonus , hyperreflexia, clonus (including ocular clonus), reactions during Plantarextension Neuromuscular hyperactivity may be stronger in the lower extremities pronounced than the top. Symptoms usually begin after 24 hours to disappear, but symptoms may continue for longer, especially after taking medicines that have a long half-life or after ingestion of the active metabolite (z. B. monoamine oxidase inhibitors, SSRI). Diagnosis Clinical criteria The diagnosis is made clinically. Various explicit criteria were mentioned. The Hunter criteria today are because of their ease of use and high accuracy preferred (almost 85% sensitivity and specificity of> 95% compared with a diagnosis of toxicologists). Place these criteria require that patients have taken a serotonergic drug, and have one of the following findings:. muscle hypertension Spontaneous clonus tremor plus hyperreflexia Ocularer or inducible clonus, plus either restlessness, sweating or temperature> 38 ° C Systemic infections, drug or alcohol withdrawal symptoms. and poisoning by sympathomimetic or anticholinergic agents should also be considered in the differential diagnosis into consideration. The differentiation of serotonin syndrome by neuroleptic malignant syndrome (Neuroleptic Malignant Syndrome) can be difficult because the symptoms (eg. As muscle rigidity, hyperthermia, autonomic hyperactivity, decreased consciousness) may overlap. Among the references to the serotonin syndrome include use of serotonergic drugs, faster onset of action (eg., Within 24 h) and hyperreflexia, in contrast to the often reduced reflexes in neuroleptic malignant syndrome. There is no confirmatory tests, but patients should be tested to rule out other conditions such. As a CSF analysis of possible CNS infection and urine tests for drugs of abuse. Also, some tests (eg., Serum electrolytes, platelets, kidney function tests, creatine phosphokinase (CPK), PT, tests on myoglobin in the urine) may be necessary to identify complications of severe serotonin syndrome. Treatment Supportive care Sometimes cyproheptadine If serotonin syndrome is recognized and treated promptly, the prognosis is usually good. All serotonergic drugs should be discontinued. Mild symptoms can be ameliorated by sedation with a benzodiazepine often h with a remedy after 24 to 72nd Even if the symptoms are resolved faster patient should be monitored at least for several hours. In most patients, however, required hospitalization for treatment, additional testing and monitoring are required. In severe cases, admission to an intensive care unit is necessary. Hyperthermia is treated by cooling (heat stroke: Treatment). Neuromuscular blockade with appropriate sedation, muscle relaxation and other supportive measures is sometimes necessary. The drug treatment of autonomic disorders (eg. As hypertension, tachycardia) should be undertaken with shorter-acting drugs (eg. As nitroprusside, esmolol) because autonomic effects can change quickly. If the symptoms persist despite supportive measures, the serotonin antagonist cyproheptadine can be administered orally, or, after crushing, via a nasogastric tube (12 mg, then 2 mg every 2 hours until a reaction occurs). Chlorpromazine and olanzapine may be effective, but not used routinely because of the possibility of adverse effects. Unlike malignant hyperthermia or neuroleptic malignant syndrome-dantrolene should not be used. A consultation with a toxicologist is advised and can be achieved by the poison is called by calling 1-800-222-1222 in the US or by accessing the WHO list of international poison centers (http: //www.who. int / gho / phe / chemical_safety / poisons_centres / en / index.html). Important Points drugs that increase serotonergic activity can lead to hyperthermia and neuromuscular hyperactivity, with complications of metabolic acidosis, rhabdomyolysis, seizures, acute renal failure and DIC. The diagnosis is likely if patients have taken a serotonergic medication and muscle hypertension, spontaneous clonus, tremor plus hyperreflexia or the combination of ocular or inducible clonus plus either restlessness, sweating or temperature have> 38 ° C. The serotonin syndrome can often from neuroleptic malignant syndrome by the use of serotonergic drugs, rapid onset of action (eg., Within 24 hours of its drug release) and hyperreflexia are distinguished. Stop taking all serotonergic drugs and enter a benzodiazepine. Treat complications aggressive and pull cyproheptadine considered