Acute Psychiatry

Question 1

Serotonin Syndrome

Answer 1

• Potentially life-threatening adverse drug reaction
• Caused by overstimulation of central and peripheral serotonin receptors
• Onset typically within 24hr of initiating or changing a serotonergic medications
• There is a range of clinical findings from barely perceptible to lethal.

Question 2

Serotonin Syndrome Symptoms

Answer 2

• Mental status changes - restlessness, agitation, excitement, confusion/delirium, stupor/coma
• Autonomic hyperactivity - diaphoresis, BP instability (hypo in severe cases), tachycardia, flushing, hyperthermia, dilatation of pupils
• Neurological hyperactivity - akathisia, tremor, clonus, myoclonus, hyperreflexia, rigidity

Question 3

Medications Serotonin Syndrome

Answer 3

• Increased serotonergic neurotransmission
  
  • Excessive use of SSRIs, SNRIs, Serotingeric TCAs (clomipramine), St. John’s wart, lithium, demerol, triptans, buspirone, tramadol, fentanyl, mathadone, ondansetron
• Agents that stimulate the release of serotoning
  
  • MDMA, cocaine, amphetamine
• Agents that inhibit the breakdown of serotonin
  
  • MAOIs, linezolide, ritonavir

Question 4

Lab Investigations Serotonin Syndrome

Answer 4

• Leukocytosis
• Rhabdomyolysis (elevated CK)
• Transaminase elevation (AST and ALT)
• Kidney dysfunction (increased Cr)
• Metabolic acidosis
• DIC (severe cases)
• Myoglobinuria

Question 5

Differential Diagnosis Serotonin Syndrome

Answer 5

• NMS
• Toxidrome (particulary anticholingeric, but SS is “wet”)
• Thyrotoxicosis
• Infections
• Delirium tremens
• Malignant hyperthermia

Question 6

Management Serotonin Syndrome

Answer 6

• Remove the precipitating drugs, supportive care, sedation with benzodiazepine

Question 7

Neuroleptic Malignant Syndrome

Answer 7

• Idiosyncratic response to antipsychotic medication
• Known to occur with all antiosychotics
• Life-threatening
• Diagnosis of exclusion

Question 8

NMS symptoms

Answer 8

• Fever
• Autonomic changes
• Rigidity - lead pipe, hyporeflexia
• Mental Status Changes - decreased awareness, confusion, obtundation unresponsiveness/coma

Question 9

Risk Factors NMS

Answer 9

• Agitation
• Dehydration
• Affective Illness
• IM injection
• High doses of antipsychotics

Question 10

Differenential Diagnosis NMS

Answer 10

• Malignant Catatonia
• Serotonin Syndrome
• Heat stroke
• Malignant hyperthermia
• Anticholinergic toxidrome
• Sepsis

Question 11

Management NMS

Answer 11

• Withdrwal of dopamine blockade