This case describes a 45-year-old male presenting with agitation, fever, hypertension, tachycardia, and other signs consistent with serotonin syndrome after ingesting Paxil, Gravol, ibuprofen, and smoking crack cocaine. The document discusses the diagnostic criteria and causes of serotonin syndrome and recommends supportive care and medications like cyproheptadine, benzodiazepines, beta-blockers, chlorpromazine, and dantrolene for treatment. Cyproheptadine appears to be an effective and safe treatment option for mild to moderate cases based on case reports and series.

1. Serotonin syndrome
SAMIR EL ANSARY

2. Global Critical Care
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3. Case: I just want to die
• 45yo male
• OD on paxil, gravol,
ibuprofen tonight
• Smoked some crack
• Recent abstinence from
EtOH
• Headache, fever X
1week
• HR125 sinus
• BP 165/105
• Temp 38.0
• RR20, sats 95%
• C/S normal
• Agitation
• Pupils 6 mm
• Hyperreflexic, clonus
• Tremulous
• Very diaphoretic
• Neck stiff
• No bowel sounds

4. Case Questions
• Is this serotonin syndrome?
• What is the differential dx?
• What tests should be done?
• What are the main treatments of serotonin
syndrome?
• Is there any evidence for the use of
cyproheptidine?

5. What is Serotonin?
• Neurotransmitter
• Mood, personality,
sleep, sex, motor, temp,
pain functions
• Very complex
• 14 receptors
• Excitatory and
inhibitory functions

6. What is Serotonin Syndrome?
• Serotonin syndrome is a constellation of
findings related to excessive stimulation of
serotonin receptors and is manifested by
cognitive, autonomic, and neuromuscular
abnormalities

7. CAN you diagnosis serotonin syndrome?
C
COGNITIVE CHANGES:
Agitation, confusion, euphoria, insomnia,
hypomania, hallucinations
A
AUTONOMIC CHANGES:
Tachycardia, HTN, fever, diaphoresis,
mydriasis, arrythmias, tachypnea
N
NEUROMUSCULAR CHANGES:
Tremor, hyperreflexia, clonus, ataxia,
incoordination, seizures

8. Sternbach’s Criteria
• Addition or increased dose of a known serotonergic
agent
• At least three of the C.A.N. criteria
• Other etiologies excluded
– Withdrawl, sympathomimetics, anticholinergics, CNS
infections, neuroleptic malignant syndrome
• No neuroleptics that have been started or increased
prior to the onset of symptoms

9. What causes serotonin syndrome?
• SSRIs
• SNRIs
• MAOIs
• Cocaine
• Amphetamines
• LSD
• Lithium
• Wellbutrin
• And many more!!

10. How is Seritonin Syndrome Managed?
• Supportive Care
• Temperature control
• Benzodiazepines
• Fluids • Other therapies
– Cyprohepatadine
– Beta – blockers
– Chlorpromazine
– Dantrolene

11. What is Cyproheptadine?
• Antihistamine with anticholinergic and
antiserotonergic properties
• Blocks 5HT1a and 5HT2 receptors
• Used as antihistamine or for appetite
stimulant in anorexia
• Recommended dosage: 4 mg po tid
• No intravenous formulation

12. Does Cyproheptadine work?
DRUG DEATHS
Cyproheptadine 5 mg/kg 5/5
Cyproheptadine 10 mg/kg 0/5
Dantrolene 20 mg/kg 6/6
Propranolol 10 mg/kg 5/5
Chlorpromazine 20 mg/kg 6/6
Chlorpromazine 40 mg/kg 0/5

13. Does Cyproheptadine work?
–Case report
– Seritonin syndrome of moderate severity
– Symptoms subsided 30 min after a 4 mg po dose
– Dose repeated in 3hrs for recurrence of symptoms

14. Does Cyproheptadine work?
–Case report
– Severe serotonin syndrome
– Cyproheptadine 8 mg po
– Level of consciousness promptly improved,
hypertonia resolved, temperature normalized

15. Does Cyproheptadine work?
–Case report
– Moderate serotonin syndrome
– Treated with cyproheptadine 8 mg po with no
effect, repeat dose at 8 hours with no effect
– Chlorpromazine 50 mg im and symptoms
improved steadily over next 2hrs

16. Does Cyproheptadine work?
–Case series of 6 patients
– All mild to moderate serotonin syndromes
– Dosing: 8 mg po and repeat q 8hr
– Responses seen within hours
– No serious side – effects noted (some
anticholinergic effects)

17. Does Cyproheptadine work?
–Case series of 4 patients
– Generally moderate severities
– Initial dose 4-8 mg po
– A few got subsequent doses of 4 mg
– Responses seen within 1-2 hours
– No serious complicated reported

18. Does Cyproheptadine work?
• May be
• VERY little literature
• Appears effective
• Appears safe
• Probably not much down side to trying

19. ? Other treatments for Serotonin
Syndrome
•Chlorpromazine
•Propranolol
•Dantrolene

20. Global Critical Care
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21. GOOD LUCK
SAMIR EL ANSARY
ICU PROFESSOR
AIN SHAMS
CAIRO
elansarysamir@yahoo.com