Mental illness and depression are on the rise across the world, so it goes without saying the prescription medications to combat these illnesses are also on the rise. SSRI's are some of the most widely prescribed treatments, but like most drugs they come with risks. Serotonin syndrome is certainly one worth mentioning and it will be the focus of this week's blog topic. This syndrome is most time characterized secondary to a drug reaction caused by prescription medications or even recreational drugs like cocaine and amphetamines -- all of which cause increases to serotonin levels within the body. Serotonin toxicity can have life threatening complications. The most common Rx culprits EMS providers need to be aware of are the following:
SSRI's (Serotonin-specific reuptake inhibitors) - blockage of reuptake pumps
Celexa (citalopram)
Lexapro (escitalopram)
Zoloft (sertraline)
Prozac (fluoxetine)
TCA (Tri-cyclic antidepressant)
Elavil (amitriptyline)
Serotonin is a neurotransmitter produced by the central nervous system. Like all other neurotransmitters, as the name implies, its overarching role is to carry messages between nerve cells. Most of the serotonin present in our body (90%) resides in our gut, to guide intestinal movements, while the remaining marginal amounts are found within the brain and circulating platelets to help with aggregation. Within the CNS the role of serotonin is vast and includes effects on sleep, mood, cognition and thermoregulation (more on this last one later)
Signs and symptoms of serotonin syndrome you should watch for are: *keep in mind some of these can manifest rather quickly:
Hyper reflexivity or clonus - involuntary muscular contractions (focus on lower limbs)
maybe seen as twitching or tremors as well
Altered mental status - GCS < 15, delirium and/or severe agitation
Autonomic problems
Diarrhea, and/or nausea
Dilated pupils
Tachycardia
Sweating or shivering
Seizures
A high temperature - sometimes > 104 F
Usually from muscle contractions and rigidity, NOT a hypothalamus issue
Risk factors for the above presentation can include a brand-new prescription or an increase in dosage. Additionally, when things drugs get combined with MAOI's (another class of depression drugs) or illicit street drugs - that can spell bad news for the patient.
The overall well-being of the human species depends on medications like the ones we described above - there are many benefits around how they change the life of the individuals suffering from depression or anxiety, but healthcare providers must remain vigilant when they are abused, combined with other substances or just simply don't agree with the patient even when they are totally compliant with the regimen.
Many times, resolution of symptoms can happen within 24 hours, treatment will be focused on keeping blood pressure within normal limits and preventing or correcting hyperthermia amongst other things. Hydration and even the use of benzodiazepines can also go a long way. The hospitals may also have access to other medications (outside of our toolbox) to help improve their symptoms. If this syndrome is caught late and hemodynamic instability is profound - this can certainly be fatal, so keep it on your short list of differential diagnosis. Attempting to get an accurate history of present illness and medication history can be crucial. Remember you're the only eyes at the scene. Always follow your local protocols - nothing on this blog supersedes your local guidelines and medical direction.
January 20, 2025
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC
Comments