serotonin syndrome ppt

1. BY-Subrat kumar Patra
IMS &SUM Hospital

2. INTRODUCTION
• Potentially life threatening adverse drug reaction.
• It may result from therapeutic drug use,
intentional self-poisoning or inadvertent
interactions between drugs
• It is a predictable consequence of excess
serotonergic agonism of central nervous system
(CNS) receptors and peripheral serotonergic
Receptors.

3. PATHOPHYSIOLOGY:
• It is a predictable consequence of excess serotonergic
agonism of central nervous system (CNS) receptors and
peripheral serotonergic receptors
• Many cases of serotonin toxicity occur in patients who
have ingested drug combinations that synergistically
increase synaptic serotonin
• It may also occur as a symptom of overdose of a
single serotonergic agent
• Addition of drug that inhibit cytochrome P450 , when
added to the therapeutic regimen of serotonergic
drugs may precipitate serotonin syndrome

6. CLINICAL FEATURES:
• The serotonin syndrome is often described as a
clinical triad:
1. Mental-status changes
2. Autonomic hyperactivity
3. Neuromuscular abnormalities
• The triad is not consistently present in all the
patients with the disorder
• Signs of excess serotonin range from tremor and
diarrhoea in mild cases to delirium, neuromuscular
rigidity and hyperthermia in life-threatening cases.

8. CLINICAL FEATURES:
• The onset of symptoms is usually rapid, with clinical findings
often occurring within minutes after a change in medication or
self-poisoning.
• Approximately 60 percent of patients with the serotonin
syndrome present within six hours after initial use of
medication, an overdose, or a change in dosing.
• The serotonin syndrome is not believed to resolve
spontaneously as long as precipitating agents continue to
be administered.

9. MILD PRESENTATION
• Patients with mild cases may be afebrile.
Physical Examination
Tachycardia
Shivering
Diaphoresis
Mydriasis
Neurologic Examination
Tremor
Myoclonus
Hyperreflexia

10. MODERATE PRESENTATION
• Abnormal vital signs
– Tachycardia
– Hypertension
– Hyperthermia with core temp of 40 C
• Physical Exam
– Mydriasis, diaphoresis
Hyperreflexia and clonus, greater in lower
extremities.

11. SEVERE PRESENTATION
Physical changes
– Hypertension
– Tachycardia that may deteriorate into shock
– Agitated delirium,seizures
– Muscular rigidity and hypertonicity, greater in lower
extremities ;may mask clonus
– Muscle hyperactivity with core temp greater than
41.1 C in life-threatening cases.

13. Differential Diagnosis
• Anticholinergic poisoning
• Malignant hyperthermia
• Neuroleptic malignant syndrome

14. MANAGEMENT
• Removal of the precipitating drug
• Administration of 5-HT2a antagonists
• Supportive care:
 correction of vital signs
administration of intravenous fluids
 the control of autonomic instability
 the control of hyperthermia
• Many cases of the serotonin syndrome typically resolve
within 24 hours after the initiation of therapy and the
discontinuation of serotonergic drugs, but symptoms may
persist in patients.

15. 5HT2A Antagonists
• Cyproheptadine is the recommended therapy for the serotonin
syndrome
• Treatment of the serotonin syndrome in adults may require 12
to 32 mg of the drug during a 24-hour period, a dose that binds
85 to 95 percent of serotonin receptors.
• An initial dose of 12 mg of cyproheptadine and then 2 mg
every two hours if symptoms continue. Maintenance dosing
involves the administration of 8 mg of cyproheptadine every
six hours.

16. Mild presentation Moderate Presentation Severe Presentation
•Supportive care
•Removal of Precipitating
Drugs
•Treatment with
•benzodiazepines
•Aggressive correction of
cardiorespiratory and
thermal abnormalities
• Administration of 5-HT 2a
antagonists
•Immediate Sedation
•Pharmacologic paralysis
•Mechanical Intubation

18. REFERENCES
o Volpi-Abadie, J., Kaye, A. M., & Kaye, A. D. (2013). Serotonin
oSyndrome. The Ochsner Journal, 13(4), 533–540.
oFrank, C. (2008). Recognition and treatment of serotonin syndrome.
oCanadian Family Physician, 54(7), 988–992.
o http://www.mayoclinic.org/diseases-conditions/serotoninsyndrome/
odiagnosis-treatment/treatment/txc-20305697
oBoyer, E., Shannon, M. (2005) The Serotonin Syndrome. New England
oJournal of Medicine. 352, 1112-1120.
o Prevention, Diagnosis, and Management of Serotonin Syndrome
ohttp://www.aafp.org/afp/2010/0501/p1139.html
o Bijl D. The serotonin syndrome. Nether J Med.2004;62:309-313.
o Dr. Santhosh Kumar
ohttps://www.slideshare.net/SanthoshKumar291/serotonin-syndrome-
o75848602/2
o Opioid Receptors: Distinct Roles in Mood Disorders
ohttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3594542/