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Serotoninsyndrome Ser

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  • Diagnosis largely clinical but can use labs to narrow the differential. Diagnosed based on clinical findings; Hunter Diagnostic Toxicity Criteria Rules.
  • Cyprohepatdine is a histamine-1 antagonist with nonspecific 5-HT1A and 5-HT2-A antagonist properties. Definitive evidence is lacking.
  • Transcript

    • 1. Morning Report November 17, 2009
    • 2. What term is used to describe this finding?
      • 1. Hyphema
      • 2. Hypopyon
      • 3. Iridocyclitis
      • 4. Iridodonesis
      • 5. Synechia
    • 3. Answer: Image Challenge What term is used to describe this finding? Q: 1. Hyphema Layering of blood in the anterior segment is termed hyphema. Hypopyon refers to pus in the anterior segment. Iridocyclitis refers to inflammation of the iris. Iridodonesis is a quivering of the iris when the patient moves the eye. Synechia is an adhesion between the iris and the lens. Read More: N Engl J Med 2008;358:2265
    • 4. What is the diagnosis?
      • 1. Dermatopathia pigmentosa reticularis
      • 2. Lichen planus
      • 3. Psoriasis
      • 4. Rubella
      • 5. Keratoderma blennorrhagicum
    • 5. Answer: Image Challenge What is the diagnosis? Q: 5. Keratoderma blennorrhagicum These vesiculopustular waxy lesions are most consistent with keratoderma blennorrhagicum. This finding should prompt diagnostic testing for sexually transmitted or gastrointestinal pathogens. Read More: N Engl J Med 2008;358:2160
    • 6. This rash appeared following treatment for leukemia. What is the diagnosis?
      • 1. Cryoglobulinemia
      • 2. Leukemia cutis
      • 3. Herpes zoster
      • 4. Graft-versus-host disease
      • 5. Urticaria pigmentosa
    • 7. Answer: Image Challenge This rash appeared following treatment for leukemia. What is the diagnosis? Q: 4. Graft-versus-host disease There is hyperpigmentation and hypopigmentation of the skin, cutaneous atrophy, telangiectasia, and ulcerations. This is most consistent with graft-versus-host disease of the skin.
    • 8. Treatment with which one of the following medications is associated with this clinical finding?
      • 1. Erlotinib
      • 2. Leflunomide
      • 3. Methotrexate
      • 4. Pegvisomant
      • 5. Psoralen
    • 9. Answer: Image Challenge Treatment with which one of the following medications is associated with this clinical finding? Q: 1. Erlotinib Erlotinib, a tyrosine kinase inhibitor of the epidermal growth factor receptor, induces characteristic hair alterations. Trichomegaly, curling, elongation, and trichorrhexis are typical; these reverse after discontinuation of therapy. The pictured changes are not typical of leflunomide, methotrexate, pegvisomant, or psoralen. Read More: N Engl J Med 2008;358:1175
    • 10. What is the diagnosis?
      • 1. Dental abscess
      • 2. Neurofibromatosis type 1
      • 3. Cleft jaw
      • 4. Hemiatrophy syndrome
      • 5. Mandibular fracture
    • 11. Answer: Image Challenge What is the diagnosis? Q: 5. Mandibular fracture This patient developed a comminuted fracture of the left and right mandible after being struck on his right lower jaw. The open fracture allowed upward displacement of the left half of the mandible. Read More: N Engl J Med 2008;358:512
    • 12. 80s Flashback! What was Madonna’s first #1 hit?
      • Papa Don’t Preach
      • Like A Virgin
      • Holiday
      • Cherish
    • 13. Physical Exam
      • VS: T 97.2F, BP 116/84, HR 120, RR 19, O2S 95% RA
      • Gen: Agitated and lying in bed. Opens eyes to voice intermittently. Tremulous and diaphoretic.
      • HEENT: Normocephalic and atraumatic. PERRL. Pt will not cooperate with opening mouth for OP exam.
      • Neck: No masses. Trachea midline. Carotids 2+
      • Lungs: CTA bil, no wheezing or rales
      • CV: Tachycardic, regular. S1 and S2 normal, no m/r/g
      • Abd: soft/nt/nd. Bowel sounds normal to hyperactive.
      • Ext: 1-2+ pitting edema in RLE. LLE without edema. Right hip surgical site is c/d/I with mild serosanginous drainage. DP and PT pulses 2/2.
      • Neuro: Not able to follow commands. Opens eyes to pain, voice and touch. Visible tremors in bil lower extremities. Spontaneous clonus in RLE, inducible clonus with multiple beats in bil LE, but R>L. Patellar reflexes 3+ bilateral. Biceps reflexes 2-3+ bil. Bil LE exhibit rigidity bilaterally. Unable to illicit babinski sign due to rigiditiy.
    • 14. Imaging
    • 15. Labs
      • CBC: WBC 10.9 (normal diff), HGb 9.2, Plt 256
      • BMP: Na+ 138, K+ 4.0, Chl 107, CO2 25, BUN 12, Crt 0.8, Ca2+ 8.0
      • Utox: preliminary  presumed pos for amphetamines and THC
      • CK 662
    • 16. EKG Sinus Tachycardia
    • 17. Serotonin Syndrome
    • 18. Serotonin Syndrome
      • Described in all age groups.
      • In 2004, the Toxic Exposure Surveillance System identified 48,204 exposures to SSRI that resulted in mod-major outcomes in 8187 patients and death in 103 patients.
      • Diagnosed based on clinical findings; Hunter Diagnostic Toxicity Criteria Rules.
    • 19. Mechanism
      • Due to excess of serotonergic activity at CNS and peripheral serotonin receptors.
        • Produce autonomic, cognitive and somatic effects.
      • Drugs that may contribute:
        • Anti-depressants (SSRIs, MAOIs, SNRIs, trazodone )
        • Opiods (tramadol, fentanyl, oxycodone )
        • CNS stimulants (cocaine, methylphenidate)
        • 5-HT agonists (triptans)
        • Psychedellics (LSD, MDA)
        • Herbs (St. Johns Wort, ginseng, nutmeg)
        • Others including:tryptophan, L-dopa, valproate, lithium linezolid, ondesetron, metoclopramide, dextromethorphan
        • (AND MORE!)
    • 20. Hunter Criteria
      • Must have taken a serotonergic agent and 1+ of the following:
        • Spontaneous clonus
        • Indicible clonus + agitation or diaphoresis
        • Ocular clonus + agitation or diaphoresis
        • Tremor and hyperreflexia
        • Hypertonia
        • Temp >38C + ocular clonus or inducible clonus
        • *Findings often more pronounced in LE.
    • 21. Treatment
      • Discontinue serotonergic agent.
      • Sedate using benzodiazepines.
      • Supportive cares: oxygen, IV fluids, cardiac monitoring.
      • Anticipate complications, VS can fluctuate widely.
      • If benzos and supportive cares not adequate, may need to use cyproheptadine.
      • Treat temperatures >41C with standard measures including intubation and sedation but try to avoid APAP.
    • 22. Prognosis
      • Good! (Unlike an attack by a slap bracelet )
        • Patients usually respond within 24 hours.
        • However, the difficulty can be a co-ingestion as this is often seen with serotonin syndrome.
    • 23. How does serotonin syndrome effect you? On that note… DON’T FORGET TO LOG YOUR WORK HOURS!
    • 24. Announcements!
      • Noon Conference: Atrial Fibrillation with Dr. Smalley.
      • 1pm Med I Lecture: ABGs with Sarah