Serotinin Syndrome and NMS

Question 1

Symptoms of NMS

Answer 1

fever sometimes (>104), AMS, generalized muscle rigidity, Autonomic instability (HR, labile BP, tachypnea diaphoresis)

Question 2

NMS is caused by:

Answer 2

antipsychotics anti emetics anti Parkinson drugs medication withdrawal (dopamine agonist) infection surgery

Question 3

Treatment of NMS

Answer 3

stop provoking mes or restarting dopamine agents, supportive care (hydration and coolin) dantrolene or bromocriptine

Question 4

NMS lab findings

Answer 4

elevated creatine kinase from muscle necrosis and leukocytosis severe cases: myoglobinuria or acute renal failure

Question 5

Drug induced parkinsonism features

Answer 5

tremor, rigidity, bradykinesia and gait abnormalities, no fever or autonomic instability

Question 6

Malignant hyperthermia is a result of

Answer 6

genetic disorder muscle rigidity and hyperthermia when exposed to volatile anesthetics or succinylcholine

Question 7

Serotonin syndrome is caused by

Answer 7

from multiple serotonergic drugs or drug interactions- ergot derivatives, SSRI/SNRI, TCA, tramadol MAOI or linezolid, or St John’s wart interactions intentional overdose of serotonergic medications serotonergic drugs of abuse (MDMA or estacsy)

Question 8

Physical exam findings of Serotonin Syndrome

Answer 8

AMS, hyperreflexia, fever, clonus, ocular clonus, tremor, autonomic instability and GI symptoms (N/V/diarrhea)

Question 9

clinical features of Serotonin syndrome?

Answer 9

mental status changes (anxiety, agitation and delirium) autonomic instability - diaphoresis, hypertension, tachycardia, hyperthermia, vomiting, and diarrhea Neuromuscular hyperactivity (tremor, myoclonus, hyperreflexia)

Question 10

Management of Serotonin Syndrome:

Answer 10

stop all sertonergic meds supportive care and sedation with benzodiazepines

serotonin antagonist (cyproheptadine) if supportive measures fail

critically ill need to be intubated

Question 11

Diagnosis of Serotonin syndrome

Answer 11

based on physical exam or clinical history, no clinical tests.

Question 12

classic triad of serotonin syndrome?

Answer 12

AMS, autonomic dysregulation, and neuromuscular hyperactivity (hyperreflexia, tremor, rigidity, myoclonus, ocular clonus, bilateral Babinski signs)

Question 13

when do we use cyproheptadine for treatment of serotonin syndrome?

Answer 13

failure of supportive care (IVF) and benzodiazepines to resolve symptoms OR hyperthermia, disorientation

Question 14

when do we ever check serotonin levels?

Answer 14

not for serotonin syndrome but rather if you’re look for carcinoid syndrome.

Question 15

Fever > 40C common confusion generalized muscle rigidity autonomic instability with abnormal vital signs and sweating

Answer 15

Neuroleptic malignant syndrome

Question 16

Treatment of neuroleptic malignant syndrome

Answer 16

stop antipsychotics (generally 1st generation), or restart dopamine agents supportive care (hydration and cooling) ICU care dantrolene (muscle relaxant) or bromocriptine (dopamine agonist) if refractory to treatment

Question 17

what is seen on labs with NMS?

Answer 17

see elevated CK from the lead pipe rigidity seen and muscle breakdown. see leukocytosis as a reactive process. can see elevated CK >1000 or rhabdomyolysis too if very severe

Question 18

single most important intervention for NMS

Answer 18

stop the causative agent and this only helps to resolve symptoms. need to rehydrate and lower body temperature. see NMS mortality of 10-20% so need to go to ICU level care

Question 19

haloperidol overdose is:

Answer 19

oversedation without GI symptoms, no myoclonus or lead rigidity.

Question 20

What is Parkinsonism hyperpyrexia syndrome?

Answer 20

This is when there’s basically neuroleptic malignant syndrome after there is Parkinson’s drugs that are withdrawn abruptly, dose reduced or a switch in dopamine agents

Question 21

stopping Parkinson’s drugs can

Answer 21

precipitate NMS - see idiosyncratic adverse effect of antipsychotic medications

Question 22

lithium toxicity presents with

Answer 22

neuromuscular symptoms like slurred speech, tremor, and ataxia No muscular rigidity or hyperpyrexia (fever)

Question 23

what precipidates malignant hyperthermia?

Answer 23

after a procedure that uses halogenated inhalant anesthetic or succinylcholine