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Serotonin syndrome 2
- 1. Serotonin syndrome SAMIR EL ANSARY
- 2. Global Critical Care https://www.facebook.com/groups/1451610115129555/#!/groups/145161011512 9555/ Wellcome in our new group ..... Dr.SAMIR EL ANSARY
- 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 https://www.facebook.com/groups/1451610115129555/#!/groups/145161011512 9555/ Wellcome in our new group ..... Dr.SAMIR EL ANSARY
- 21. GOOD LUCK SAMIR EL ANSARY ICU PROFESSOR AIN SHAMS CAIRO elansarysamir@yahoo.com