Professional Documents
Culture Documents
TEEN
HPI
13 year old female
Brought to ED by her father
Sudden onset of falling, confusion,
eventually vomiting
Acting normally when she got home from
school
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Toxic
Ingestions: anticholinergic, sympathomimetic, salicylates, serotonin-syndrome
Withdrawal states: Barbiturates, ethanol (DTs), sedative-hypnotics
WORK UP
CBC: Normal
BMP: Normal
CK: Normal
VBG: 7.34/33/65/17.2
Serum tox: Negative EtOH, acetaminophen, salicylate
Urine tox: + PCP, + Opiate
Urine pregnancy: Negative
EKG: Sinus tachycardia. Normal QTc.
ADDITIONAL HPI
Grandpa calls with more information
Recent suicidal threats
Admits to an ingestion of a handful of pills
from local grocery store
Prescription pills counted, all accounted for
ADDITIONAL HPI
Called Poison Control back with additional information
Consulted toxicology
Learned that DEXTROMETHORPHAN:
Causes false positive drug screens
Is a dissociative general anesthetic & hallucinogen
at high doses
Is what kids these days are doing for fun
When mixed with serotonergic meds, can cause
SEROTONIN
SYNDROME
FEATURES OF SEROTONIN
SYNDROME
Cognitive/Behavioral
Confusion/disorientation
Agitation/irritability
Coma
Anxiety
Hypomania/seizures/
hallucinations
Autonomic
Hyperthermia
Diaphoresis
Sinus tachycardia
Hypertension
Tachypnea/mydriasis
54%
35%
28%
16%
15%
46%
46%
41%
33%
27%
Neuromuscular
Myoclonus
Hyperreflexia
Muscle
rigidity/tremor
Hyperactivity/
restlessness
Ataxia
57%
50%
49%
42%
38%
MEDICATIONS
Antidepressants
Antiemetics
Ecstasy
Buspirone
Metoclopramide
Dextroamphetamine
Lithium
Ondansetron
Methamphetamine
MOAIs
Antimigraine Drugs
Sibutrimine
SSRIs
Carbamazepine
SNRIs
Ergot alkaloids
Cyclobenzaprine
Trazodone
Triptans
Fentanyl
TCAs
Valproic acid
Analgesics
Meperidine
Miscellaneous
Tramadol
Cocaine
Dextromethorphan
Linezolid
St. Johns Wort
TREATMENT
Stop all serotonergic medications
Symptom control
Hyperthermia: external cooling measures
Agitation, myoclonus: benzodiazepines (Lorazepam 0.02 to 0.04 mg/kg/dose in
children)
Opiates
Phencyclidine
Dextromethorphan
Dextromethorphan
Diphenhydramine
Diphenhydramine
Fluoroquinolones
Dextroamphetamine
Doxylamine
Rifampin
Ibuprofen
Quinine
Imipramine
Ketamine
Meperidine
Thioridazine
Tramadol
Venlafaxine
REFERENCES
Ables, A et al. Prevention, Diagnosis, and Management of Serotonin
Syndrome. American Family Physician. 2010; 81 (9) 1139-1142.
Arnold, D. Consultation With the Specialist: The Central Serotonin
Syndrome: Paradigm for Psychotherapeutic Misadventure. PEDIATRICS
IN REVIEWDecember 1, 2002vol. 23no. 12427432doi:10.1542/pir.23-12-427
UpToDate: Serotonin Syndrome
Woelfel JA. Drug abuse urine tests: false-positive results.Pharmacist's
Letter/Prescriber's Letter2005;21(3):210314.