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Episode 939: Serotonin Syndrome

Emergency Medical Minute

Release Date: 01/13/2025

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Emergency Medical Minute

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Episode 966: Acetaminophen Toxicity show art Episode 966: Acetaminophen Toxicity

Emergency Medical Minute

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Emergency Medical Minute

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Episode 964: Ketamine & Midazolam for Prehospital Seizure Management show art Episode 964: Ketamine & Midazolam for Prehospital Seizure Management

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Prehospital seizures are typically managed with intramuscular midazolam (Versed) Seizures theoretically involve the NMDA pathway, and ketamine is a potent NMDA antagonist A recent retrospective cohort study analyzed a Florida EMS protocol that uses ketamine in seizures refractory to midazolam One group received two doses of midazolam for seizure control The other group received a dose of midazolam followed by a dose of ketamine After matching, 82% of the midazolam-only group patients had resolution of convulsions prior to ED arrival 94.4%...

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Episode 963: Antihypertensives and Emergency Room Considerations show art Episode 963: Antihypertensives and Emergency Room Considerations

Emergency Medical Minute

Contributor: Alec Coston, MD Educational Pearls: For patients presenting to the emergency room with hypertension, clinicians should determine if it is isolated and uncomplicated, or involves comorbidities with more complex underlying pathophysiology.  For uncomplicated and isolated hypertension, first-line treatment is thiazide diuretics.  How do thiazide diuretics work to treat hypertension? Thiazide diuretics work by blocking sodium and chloride resorption in the kidneys.  “Where sodium goes, water follows,” thus promoting diuresis and lowering blood pressure. Examples...

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Emergency Medical Minute

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Episode 960: Frank's Sign - A Marker for Coronary Artery Disease show art Episode 960: Frank's Sign - A Marker for Coronary Artery Disease

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls Frank’s sign is a curious physical exam finding first described in the literature in 1973 Bilateral earlobe creases are recognized as a marker of coronary artery disease and cerebrovascular disease Some studies have found an increase in all-cause mortality in patients with bilateral diagonal earlobe creases The pathophysiology is still not fully understood One 2020 study found histopathological changes associated with diagonal earlobe creases, potentially linking them via a model of hypoxia/reoxygenation References Elliott WJ,...

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Episode 959: The KLM Flight Disaster and Lessons in Healthcare Communication show art Episode 959: The KLM Flight Disaster and Lessons in Healthcare Communication

Emergency Medical Minute

Contributor: Taylor Lynch, MD Educational Pearls: The KLM Flight Disaster, also known as the Tenerife Airport Disaster, occurred on 27 March 1977. It involved the collision of two Boeing 747 passenger jets from KLM and Pan Am Airlines, resulting in 583 fatalities.  What fell through the cracks to cause this incident? The captain of the KLM flight believed he had received clearance from air traffic control to take off, when in fact he had not. This captain was one of the most senior pilots in the organization, and the culture often saw senior pilots as infallible and not to be questioned....

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More Episodes

Contributor: Jorge Chalit-Hernandez, OMS3

Educational Pearls:

  • Serotonin syndrome occurs most commonly due to the combination of monoamine oxidase inhibition with concomitant serotonergic medications like SSRIs

  • Examples of unexpected monoamine oxidase inhibitors

    • Linezolid - a last-line antibiotic reserved for patients with true anaphylaxis to penicillins and cephalosporins

    • Methylene blue - not mentioned in the podcast due to its uncommon usage for methemoglobinemia

  • Other medications that can interact with SSRIs to cause serotonin syndrome

    • Dextromethorphan - primarily an anti-tussive at sigma opioid receptors that also has serotonin reuptake inhibition

  • Clinical presentation of serotonin syndrome

    • Altered mental status

    • Autonomic dysregulation leading to hypertension (most common), hypotension, and tachycardia

    • Hyperthermia

    • Neuromuscular hyperactivity - tremors, myoclonus, and hyperreflexia

  • Hunter Criteria (high sensitivity and specificity for serotonin syndrome):

    • Spontaneous clonus

    • Inducible clonus + agitation or diaphoresis

    • Ocular clonus + agitation or diaphoresis

    • Tremor + hyperreflexia

    • Hypertonia, temperature > 38º C, and ocular or inducible clonus

  • Management of serotonin syndrome

    • Primarily supportive - benzodiazepines can help treat hypertension, agitation, and hyperthermia. Patients often require repeated and higher dosing of benzodiazepines

    • Avoid antipyretics to treat hyperthermia since the elevated temperature is due to sustained muscle contraction and not central temperature dysregulation

    • In refractory patients, cyproheptadine (a 5HT2 antagonist) may be used as a second-line treatment

    • Patients with temperatures > 41.1º C or 106º F require medically induced paralysis and intubation to control their temperature

References

  1. Boyer EW, Shannon M. The serotonin syndrome [published correction appears in N Engl J Med. 2007 Jun 7;356(23):2437] [published correction appears in N Engl J Med. 2009 Oct 22;361(17):1714]. N Engl J Med. 2005;352(11):1112-1120. doi:10.1056/NEJMra041867

  2. Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96(9):635-642. doi:10.1093/qjmed/hcg109

  3. Ramsay RR, Dunford C, Gillman PK. Methylene blue and serotonin toxicity: inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction. Br J Pharmacol. 2007;152(6):946-951. doi:10.1038/sj.bjp.0707430

  4. Schwartz AR, Pizon AF, Brooks DE. Dextromethorphan-induced serotonin syndrome. Clin Toxicol (Phila). 2008;46(8):771-773. doi:10.1080/15563650701668625

  5. Thomas CR, Rosenberg M, Blythe V, Meyer WJ 3rd. Serotonin syndrome and linezolid. J Am Acad Child Adolesc Psychiatry. 2004;43(7):790. doi:10.1097/01.chi.0000128830.13997.aa

Summarized & Edited by Jorge Chalit, OMS3

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