Serotinin Syndrome and NMS Flashcards
Symptoms of NMS
fever sometimes (>104), AMS, generalized muscle rigidity, Autonomic instability (HR, labile BP, tachypnea diaphoresis)
NMS is caused by:
antipsychotics anti emetics anti Parkinson drugs medication withdrawal (dopamine agonist) infection surgery
Treatment of NMS
stop provoking mes or restarting dopamine agents, supportive care (hydration and coolin) dantrolene or bromocriptine
NMS lab findings
elevated creatine kinase from muscle necrosis and leukocytosis severe cases: myoglobinuria or acute renal failure
Drug induced parkinsonism features
tremor, rigidity, bradykinesia and gait abnormalities, no fever or autonomic instability
Malignant hyperthermia is a result of
genetic disorder muscle rigidity and hyperthermia when exposed to volatile anesthetics or succinylcholine
Serotonin syndrome is caused by
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)
Physical exam findings of Serotonin Syndrome
AMS, hyperreflexia, fever, clonus, ocular clonus, tremor, autonomic instability and GI symptoms (N/V/diarrhea)
clinical features of Serotonin syndrome?
mental status changes (anxiety, agitation and delirium) autonomic instability - diaphoresis, hypertension, tachycardia, hyperthermia, vomiting, and diarrhea Neuromuscular hyperactivity (tremor, myoclonus, hyperreflexia)
Management of Serotonin Syndrome:
stop all sertonergic meds supportive care and sedation with benzodiazepines
serotonin antagonist (cyproheptadine) if supportive measures fail
critically ill need to be intubated
Diagnosis of Serotonin syndrome
based on physical exam or clinical history, no clinical tests.
classic triad of serotonin syndrome?
AMS, autonomic dysregulation, and neuromuscular hyperactivity (hyperreflexia, tremor, rigidity, myoclonus, ocular clonus, bilateral Babinski signs)
when do we use cyproheptadine for treatment of serotonin syndrome?
failure of supportive care (IVF) and benzodiazepines to resolve symptoms OR hyperthermia, disorientation
when do we ever check serotonin levels?
not for serotonin syndrome but rather if you’re look for carcinoid syndrome.
Fever > 40C common confusion generalized muscle rigidity autonomic instability with abnormal vital signs and sweating
Neuroleptic malignant syndrome
Treatment of neuroleptic malignant syndrome
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
what is seen on labs with NMS?
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
single most important intervention for NMS
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
haloperidol overdose is:
oversedation without GI symptoms, no myoclonus or lead rigidity.
What is Parkinsonism hyperpyrexia syndrome?
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
stopping Parkinson’s drugs can
precipitate NMS - see idiosyncratic adverse effect of antipsychotic medications
lithium toxicity presents with
neuromuscular symptoms like slurred speech, tremor, and ataxia No muscular rigidity or hyperpyrexia (fever)
what precipidates malignant hyperthermia?
after a procedure that uses halogenated inhalant anesthetic or succinylcholine
