Roundtable – Seritonin Syndrome

Seritonin Syndrome

What I thought that we’d talk about is a syndrome that has some very, very dire consequences when it happens. And the bad news is that it’s not the easiest diagnosis to make. And so it tends to be something that sometimes is, well not sometimes, is very often missed.

And especially in very mild cases, it may be something that we just don’t even think about. And we probably should. And I remember the first time that I heard a lecture about this back in the, I guess it was probably early 2000s.

I remember at the end of the lecture, one of the participants in the meeting stood up and the speaker said, do you have a question? And he goes, no, I have to go and make a phone call because I think I missed a diagnosis of this just last night and I need to call and let the hospital know. So it’s something that is still, I think, not really thought about very often. And I am sure that I can look back and find times where I probably had missed the diagnosis as well.

So let’s talk a little bit about this. First topic really kind of became a topic that everyone talked about due to this young lady here. Name was Libby Zion.

The circumstances surrounding her death ended up changing medicine in so many ways. And since you weren’t around beforehand, you realize all the different ways that it changed things. Juliana, I need you to change your name to the course number in your name so that you can get credit.

See that you just logged on and I’m sure that you already knew that, but we’ll go ahead and remind you anyway. First off, Libby was an 18 year old. She was a college student and she lived in New York City, but she was she was actually attending school in another city and had come home and she ended up going to the hospital.

She was admitted to Cornell Medical Center in New York City because she was having agitation and flu-like illness. She was seen in the ER there by an intern and a resident and they called her primary care doctor who agreed with admitting her to the hospital, but he did not come and see her. She was taking Nardil, an antidepressant, which is in the monoamine oxidase inhibitors or the MAOI class of drugs.

And they were very popular and they’re still somewhat popular even now, but at the time things were rather different as far as how all of the systems work together. They said that she was having a lot of jerking movements and seeming agitated and so they gave her Meparidine or Demerol for these jerking movements. When they did that, she actually got more agitated, so they gave more Meparidine, which gave even more agitation.

They actually got her admitted to the hospital and the intern and the resident during the night went to go and try to get some sleep. They were on a 36-hour shift at that point and they called the intern when she started to pull out her IV and so they ordered physical restraints, so they tied her down to the bed. They also said, well, let’s give her some Haldol because that will help to bring her down a little bit.

And then her temperature started to climb up to a 107 Fahrenheit and they called the intern again and they very appropriately started trying to do some cooling measures, but by the time the intern was able to get from the building that she was sleeping in over to the building where the patient was admitted, there were more than one building in this hospital complex, she was already in cardiac arrest and they were unable to resuscitate her. So a few things that kind of come into play with this particular case, there were no computerized pharmacy services back then. This was in the late 80s that this occurred.

I believe it was 1984 or 1985. There was little drug interaction information that was taught at that point. Most of the things that were taught then about drug interactions were the absolute do not do this ever because they’ll interact with each other and have an immediate really bad consequence and we just didn’t know a lot about this.

Additionally, the residents provided all the care. They’re usually in that time in medical training. There were no attending physicians that were in the building unless they were working in the ER or they were in a surgery.

They were actually physically doing something at that point, so they weren’t there to provide oversight. They were working up to 36 hours at a time and they were often putting in 120 to 136 hours per week. It was not in common even when I was in training in the 90s for us to work a 12-hour shift and then once you got done with all the duties at the end of that 12-hour shift you could go home.

Then you would come back for another 12 and then same thing again and then on the third one you were there for 36 hours. So you would work your 12, work a 12-hour overnight and then another 12 and then you could finally go home. Often these stretched into many more hours because the shift was over you still had chores that you had to get done, charting, putting in a line or any number of other tasks that still had to be done.

That particular night that intern was responsible for 40 patients. Now we have work hour restrictions. Now this young woman died of this thing called serotonin syndrome and yes there’s been a lot of education about serotonin syndrome since then but the repercussions that led to her death have reached so much further than that and as a result of that we now have work hour restrictions for residents.

They were put into place in essentially 20 years after she died in 2003. They have tried to reach out and get other agencies involved in some of these things as a result of this and it’s it’s been very I guess you’d say upsetting in a sense to medical education and has really changed a lot of things about that. Right now this is current restrictions.

They cannot work more than 80 hours on average over four weeks inclusive of all in-house call activities. They have to have at least 10 hours off but between duty periods and after in-house call. 24-hour limit on continuous duty so you can’t do that 36 hour shift anymore and then you cannot accept a patient after 24 hours of continuous duty so if your shift ends at 7 a.m. you got to wait for the next person to come in before you can give somebody a patient and one day and seven must be free from patient care and education.

Once again this is averaged over four weeks so if you get two two-day weekends then you may have two weeks in between where you’re working continuously. In-house call no more than once every third night again averaged and they now require in-house attending coverage. So now we do have physicians that are in-house to supervise the residents.

So let’s get into what we’re really talking about though. I mostly want you to understand that as a result of this particular syndrome there have been a lot of changes and a lot of other things and and you can even probably thank the Libby Zine case for some of the electronic medical records that we have now because there was a lot of criticism about things not being documented not knowing and now I can’t order sometimes a medication without having to answer 40 questions about is it really gonna be okay to take this and this together even though we’ve done those now for years. So serotonin syndrome and I’ve downloaded this from StatPearls.

If you’re not familiar with StatPearls it’s part of the National Institutes of Health and National Library of Medicine. It’s free they will let you log in and create an account and you can actually take some online educational questions after each of the things are they’re really nice and they do have some EMS focus as well. So definitely that’s a good resource for you.

Serotonin syndrome is potentially life-threatening and is precipitated by use of serotonergic drugs and it may be the consequence of therapeutic use interactions or recreational drugs or even overdose. So the drugs that we’re talking about are things such as the selective serotonin reuptake inhibitors so citalopram, s-citalopram, fluoxetine, paroxetine and sertraline and these work as antidepressants by inhibiting the reuptake of serotonin at the nerve. Additionally then you also have some other medications that will further increase serotonin release in the form of the the classic one is Demerol and thanks to this interaction really hardly anybody uses Demerol.

In fact I can’t think of an ER that I’ve worked in in the last 10 years that even has Demerol. Tramadol though can cause it, pentazocine, reglan, metoclopramide, valproic acid, tegratol, carbamazepine, dextromethorphan and cyclobenzaprine or flexeril. All of those can can cause serotonin release.

Then we also have serotonin modulators such as trazodone, dopamine and norepinephrine reuptake inhibitors such as buspar, buprion, tricyclic antidepressants, the supplement st. John’s wort that is over-the-counter and taken by so many people for depression and they may not tell you that they’re on it because it’s not a prescription. You have to ask about some of these things.

MAOIs, the monoamine oxidase inhibitors such as phenelazine, transcyclopyrine, isocarboxazid. There’s so many of them and then even some antibiotics such as linozolid and even methylene blue. So has anybody seen methylene blue like in the cyanide overdose kits? Old Lilly cyanide kit had methylene blue in it and actually, Michael, we’re coming to that as well.

Amphetamine, cocaine, ecstasy and levodopa all will increase serotonin release. All of these things, if you think about it as something that is going to elevate mood and elevate activity, these are the things that pretty much all increase serotonin. Also serotonin norepinephrine uptake inhibitors will also do that.

So SSRIs and SSNRIs will all potentially cause this problem. So the hallmark of it is an altered mental status, autonomic dysfunction and neuromuscular excitation. So I’ve got a couple of videos, hopefully I can get them to play in a little bit to show you some of the stuff.

The problem is there’s no test that you can do for this. You can’t send a blood sample to a lab or something like that to tell if somebody’s going to have these or if they do have this going on. Now there are some diagnostic criteria, principally this Hunter criteria, and this is where we’re going to come up with some of the videos in just a second.

So it requires a history of exposure to a serotonergic drug and then one or more of the following. Spontaneous clonus. Now I know the question is going to come up, what is clonus? That’s what the videos that I’m going to try to show you will demonstrate better than I can describe.

Inducible clonus with agitation and diaphoresis. So you think about somebody, if you’ve ever picked up a patient at a rave where everyone’s doing ecstasy, you see this. They’re agitated, they’re diaphoretic, they’re sweating, they’re drinking water all the time.

That is a form of this. Ocular clonus with agitation and diaphoresis. Okay, so they may just have eyes that are twitching, but it’s a very characteristic kind of a twitch.

Tremor and hyperreflexia. So they’re shaking all over like a leaf and if you do reflexes on them, they’re hyperreflexic, so they’re too reflexic. Hypertonia.

Once again, the video is going to show you a really good example of that. And a temperature over 38 centigrade with ocular or inducible clonus. So think about everything is turned up in these folks.

So then the next question is, what exactly is this clonus? So clonus is a rhythmic oscillating stretch reflex that is related to upper motor neuron lesions and clonus is accompanied by hyperreflexia. Testing for clonus is performed as part of the neuro exam and it is very easily tested and you don’t even have to have any equipment. So let me see if I can get the video to come up that I would like to show you.

Let me close a couple of windows here for a second. I’ve closed out the chat window, so if you want to ask me something be sure and unmute. Okay, so that is hyperreflexia and then this is clonus.

It’s like she’s tapping her toes, but she can’t stop that. And then here is ocular clonus. This is the same patient and see how rigid she is.

It’s reported that this patient actually died the next day, but see how stiff and rigid her extremities are. Okay, so let me get to the right place again. Any questions up to this point? Michael asked a great question and Colby, anybody else up to this point? A lot of times these videos can show you these things better than it can be explained.

And so I would urge you to look into some of these things. Obviously that was just simple YouTube, so it’s not that difficult to get some of these things. But the ocular clonus is basically just like the clonus in the foot and you can also get clonus in the upper extremities as well.

It’s a stretch reflex, but it doesn’t stop. And so when you have, I believe it’s five to ten beats, that’s considered pretty strong clonus. Okay, so clonus is only when you, to Kalman, is only when you are grabbing the foot or the wrist.

And I’ll show you, so you can test for clonus this direction as well just with the hand. So a reflex is just one time. Okay, you tap a reflex area and it just bounces once.

A tremor is just a involuntary movement that is not due to a stimulus directly. So that’s really the biggest distinguishing factor is whether or not you had to do something to cause that. So clonus is that, I can’t do it voluntarily, but that tapping of either the wrist or lower extremity of foot due to stretching.

Whereas a tremor is just there all the time. It’s a good question though. So as far as the distinguishing between the, are you talking about tetanus, the disease, or are you talking about tetany, which is, you know, a prolonged spasm basically.

Was that what you were trying to ask there, Chen? You can unmute as well if you need to. Yeah, the symptoms. Okay, well are you talking about tetanus, the infection, or tetany, the neuromuscular activity? Okay, so with tetany, that is just a prolonged spasm that has a little bit of a flutter to it.

So, you know, and in a way she kind of has a titanic position in that last video when her arms are so stiff. So they’re related in a sense, or you’d almost say that they’re along the same spectrum. Good question.

Thank you, doctor. Okay, so let’s talk a little bit about the differential diagnosis. So let’s see, Benson has mentioned there’s no specific lab test, but are there any lab tests that may provide, may clue the provider in? No, actually there are none.

This is a clinical diagnosis. This is, you just have to really kind of have a suspicion about it, and it’s not something that we think about real often. And Donna, yes, we’re gonna get to the treatment in a little bit.

Benzodiazepines are definitely one of the big things that we use to try to treat this. So oftentimes we may mistake this for tremor and restlessness just in anxiety. If there are GI symptoms present, and there are a lot of serotonin receptors in the GI tract, then we may think that they just have simple food poisoning.

You may think that it’s malignant hyperthermia. Now malignant hyperthermia is actually going to be due to medications, but there are medications that were given just recently. Whereas serotonin syndrome, maybe they’ve been on the serotonin reuptake inhibitors for years, and now somebody gave them a prescription for Flexeril, and now they end up having the symptoms.

So, but the malignant hyperthermia is usually due to a certain class of medications, and it’s usually anesthetics. Malignant neuroleptic syndrome, they’re on neuroleptic drugs, so those are certain psychiatric medications. And anticholinergic toxicity, but they are on anticholinergic drugs, but a lot of those cross over in other sympathomimetic toxicities.

And once again, infectious causes. It’s often mistaken for encephalopathy or meningitis. So, you know, there’s a lot of things that this can look like, and once again, that’s the problem.

There’s no specific test for this, and even for a lot of the other things that are listed there, there’s not a specific test that we can do that comes back and, you know, puts the diagnosis on the patient. You have to think about them. So, treatment.

The most important thing about the treatment is you got to recognize it, and it’s a very difficult thing to think about sometimes, because there are so many things that this could be, including, you know, simple psychiatric issues. So, once again, there is no test. The key treatment is remove the offending agent or agents.

So, you know, if you gave something to somebody that, you know, Ultram or something, Tramadol, and now they’re having symptoms of this, obviously you need to do something so that they don’t take that again, and then you need to start trying to do what you can to treat this. Now, usually the mild things are just simple supportive care, and the forms of IV fluids, hydration, and, you know, making sure that they’re not nauseated, throwing up, and also, once again, here’s the benzodiazepines that Donna was alluding to, but you avoid antipsychotics, okay? So, things such as Haldol, Geodon, those sort of medications, you’ve got to stay away from them, and the temptation, because they get agitated with this, and they may be awake and talking to you, but they get very agitated, and of course, you know, everyone thinks, oh, well, give them the old B52, which is Haldol, Benadryl, and Ativan. The Ativan’s fine, but the other two things you really shouldn’t be giving with this, IV fluids and cooling measures.

Probably one of the key hallmarks to take out of the criteria that we listed earlier is hyperthermia. They have a fever, but it’s not due to infection. So, sometimes they may, and it should have said severe hyperthermia, may require sedation or intubation.

So, that’s my mistake. That should be hyperthermia. So, when they start getting these very high temperatures, you have to do something to stop their muscle activity, because a muscle activity is what’s building their temperature.

So, think about it, when you get a flu or something, you shiver, and that raises your body temperature. They’re doing this all on their own without an infection, okay, and some of the highest temperatures that I’ve ever seen have been in people that are abusing amphetamine, especially, but also cocaine. If they’re hypotensive, you may end up having to put them on vasopressors, but a lot of times their blood pressure is very high, so, and it can be very, very labile in between these things, and so, you may have a patient that one minute has a blood pressure of 200 over 100, and then turn around before you can even do anything about that, and now they’re down to 90 over 60.

So, it can be very, very labile as well, and so, this points out that if you’re, if you’re really having somebody that’s really bad sick with this, the best thing that you can do is going to be to go ahead and start trying to get them as sedated as possible with benzodiazepines, and, and consider even doing RSI on them so that they’re not shivering anymore. So, question from Michael, is there, is there a person presenting with posturing? Well, posturing is a totally different thing, okay, you’re, you’re talking about like the GCS type of posturing, and with that, let me come over here, and so, when, when you’re talking about posturing in that particular sense, like from GCS, you’re talking about in response to a stimulus, okay, so you provide like a sternal rub, and they, you know, the cerebral, the corticot posturing, this is different, this is, they’re just stiff, they, they get rigid. Any trends with other vital signs or the presentation besides fever? Yeah, a lot of times, they, they will present with elevated blood pressure, and they’re, they’re agitated, so those are really the big things.

Think everything is turned up, so if you suspect it, should you withhold IV? No, actually, go ahead, because you’re, you’re gonna need to give them fluids, okay, you obviously don’t want to give them medicine to raise their blood pressure, such as norepinephrine, things like that, epinephrine, but the IV fluids, they’re gonna need because they’re typically diaphoretic. If you, if you recall in the Hunter criteria, diaphoresis was, was in most of those criteria, so yes, you do need to go ahead and give them IV fluids. What else, and if I haven’t said it yet, I’ll say it, and that is be sure and do a really good history and physical examination.

You’ve got to get all the medications, including asking whoever, do they take any, you know, over the counter supplements, any herbal medicines, those sort of things, because otherwise you may end up missing that they’re on St. John’s wort, but anytime that you, that you get called out for somebody that’s somewhat agitated and altered, really should think about this. Yes, I do have, the acidosis is probably what kills most of these people, and it’s just, it’s lactic acidosis from all the, all the muscle activity. Excellent point.

And y’all can unmute your mic and talk, it’s okay. I have a question. In the EMS setting, what is the most common thing that it’s mistaken for, like the knee jerk reaction that people, that paramedics assume is the problem rather than this actual diagnosis? Probably excited delirium, so you’re, you’re thinking that it’s somebody that’s psychotic, or they’re on drugs, and, and they are, but the, we, we tend to instead, and chances are, if you look at most of these in custody deaths where, you know, EMS got called, and they were, they were agitated, and they were fighting with the cops and stuff, this may be playing a part in that as well, and it’s very, very likely that it, that it is part of that whole constellation of excited delirium.

Excellent question. Anybody else? This is a, in my opinion, this is one of those things where if you don’t think about it, you’re never gonna make the diagnosis, and that’s the case for essentially everything in medicine, that if you don’t think about it, you’ll never make the diagnosis, and I have a feeling that this is probably a lot more common than we have ever thought, and so, you know, it’s more a matter of, you know, let’s talk about this just to put it in the back of our mind, and once again, the key case in all of this was libby Zion, and it has revolutionized medicine literally around the world, especially in the, in the form of physician training, because there was, there was some bad problems with that. Colby, did you have a question? I do, yes.

With regards to the nausea vomiting, can zofran cause any issues with, like, exacerbating this? No, it works through a different mechanism, and so it’s not been listed as anything that, that has ever caused any issues with it, so I think that you’d be safe with that. But not promethazine, correct? That would make it work? Correct, or metoclopramide. So reglan and, reglan, compazine, and fenergan probably should be avoided.

Okay, okay. And, you know, if you need to, then, you know, intractable vomiting, especially with ultramental status, you probably need to protect their airway more than anything. You know, you can always turn them aside and let that just roll out as long as you’re protecting the airway.

Come back again to ABCs. If you’ve heard any of my, my talks, you know that I really want you to assess a patient and reassess a patient, and then come back and reassess again, and always starting with ABCs. If you, and even out in the field, you know, airway, I’m checking their airway, I’m checking their breathing, I’m checking their circulation, you know, I’m just feeling your pulses right now, man.

You know, those sort of things, it’ll, it will save you so many times. So ketamine and Versed for excited delirium situations. The ketamine potentially could make it worse, okay? The Versed is definitely fine, but at the same time, you also have to protect yourself and others.

So, you know, it’s one where once you get them down with ketamine, that may actually not be a bad thing because of how it acts. It acts through a different mechanism, the NDMA system, rather than going through the same GABA and other things. So the, the two of those together may actually turn out to help with that.

I could not find anything about ketamine in serotonin syndrome, but, you know, my gut tells me that it probably would be a good thing because of how it does act in the brain. You know, I know I just told you the opposite right before that, but that was as I was thinking through it in my head. So, you know, the Versed is always going to be fine for this because it’s a benzo.

In the benzodiazepines are one of the mainline treatments for this. Now, there’s not really a good way to tell, Kalman. I see the, see the question there and, and I wish that it were easy.

I think it’s more a matter of, you know, probably at the, after things have calmed down and after the patient has either recovered or succumbed to it, then at that point, that’s probably where people will finally come down with a diagnosis. But, you know, sometimes even when you put a diagnosis on paper, it’s not necessarily always the right one. And yes, so James, you ask about affecting the heart rate.

It will. These, these folks, everything is ramped up. Their tachycardic, their, their tachypneic, everything is ramped up.

So suspect in the moment Versed should be the go-to. Yes. In my opinion, any, any of the benzodiazepines are going to be a good option for this.

You know, if I see somebody that’s, that appears anxious and somewhat agitated in the ER, you know, my go-to is, you know, give them two milligrams of Versed. Two milligrams is not going to, you know, put them totally obtunded. And it may be enough to kind of chill things out a little bit to where then you can, can get a better assessment.

So, you know, you can always put more in. It’s hard to get it out though. So that’s why I would rather start, start low and go slow.

But excellent question. So Michael, no, in general, first off, remember that we’ve got multiple nervous systems. And so yes, you may end up causing them to drop their blood pressure with paralytics.

But at the same time, the heart itself is, is, it beats on its own. It’s separate. And so you generally don’t end up seeing things like that.

Now the, if all of a sudden they release a whole bunch of lactic acid, you can certainly end up, you know, having some issues related to acidosis. But in general, if you sedate these folks and, or even paralyze them, they generally just have improvement of their symptoms. Excellent question though.

Do vagals have any effects with them? Positive effects? Vagal maneuvers? Yes, sir. No, they’re, they probably won’t. For one thing, they’re, they’re not going to follow instructions.

I mean, they saw the video of those folks. They’re, they’re not doing anything voluntarily that you ask them. Okay.

What else? Anything different with OB patients with serotonin syndrome? No, because you got to save mom. If you, if you don’t save the mother, then the baby is dead. Okay.

So let me ask you this good question. Since we don’t give any benzos to pregnant, pregnant women, only max sulfate if they’re seizing, would we withhold benzos still in serotonin syndrome or just still, still go with it? No, you, you can give benzos in pregnancy. Oh, sorry.

Sorry. I got that mixed up with, with whatever else. Well, I mean, you, you would not treat the, treat seizures in pregnancy.

Yes. Yes. That’s what I was, that’s what I was going at.

Yeah. So, you know, keep in mind, this is not the same as seizures. Okay.

And so, and even if you didn’t think that this was seizures in pregnancy, go ahead and give them magnesium first. Okay. You can always give them benzos on top of that.

Okay. Okay. Anything else? So Barbara says there was a case here with similar symptoms, but the kid ended up having a salicylic acid overdose.

Does that typically present similar? Yes, it does. Because salicylism, okay, is the actual term for it. An aspirin overdose in, and there’s a number of other things.

Methyl salicylate is in several other things and methyl salicylate, especially in a child, oil of wintergreen. That is one of the toxins that just a swallow can be fatal to a child. So they’re very similar because you do get tachycardia, you do get agitation, you get a severe acidosis with it.

If you’ve ever taken one gram of aspirin at one time, you will find out what tinnitus or tinnitus is like, because everyone that takes doses like that, which is really kind of the minimum dosing. When we were using aspirin for arthritic conditions, especially rheumatoid arthritis, they were giving a gram of Tylenol, or not Tylenol, a gram of aspirin multiple times throughout the day. And one of the things that they would ask them is, are your ears ringing? If your ears aren’t ringing, you probably need to increase your dose.

So they had them right on the edge all the time. When you say a kid, I guess the question is, he was 19. Then the question is, was it excited delirium or was it serotonin syndrome? And they’re probably on the same spectrum.

They’re somewhere near each other. I’m sure that there’s a crossover between those two things. And yeah, unfortunately, a lot of folks, especially if you were here when we were talking about the positional asphyxia and excited delirium, those are things that are on the same spectrum.

So the aspirin overdose, that’s one of those things that you’re going to have to… That’s why we do tox screens that we do, including getting an alcohol salicylate and acetaminophen on all potential overdoses, even if they’re not there as a suicidal sort of thing. It’s part of part of the standard that we do automatically in most emergency departments. That’s a good case, though.

Hi, I have a question. Yes. So I was reading the other day that there has been like this trend where kids are overdosing on Benadryl.

Should we have like a high index of suspicion after the Benadryl ingestion that maybe this is happening to them? That’s I certainly would always, you know, I’ve got somebody that’s agitated. I really think that I would always want to think about this as part of the differential for that. You know, of course, Benadryl is an anticholinergic drug.

And so one of the problems is that when you overdose on those, you also start to hallucinate and get somewhat agitated. And so that’s part of, I guess, why the allure is there to overdose on. It is because, you know, you get those get the hallucinations and things like that.

To me, that doesn’t sound like that would be a very fun thing to do. But whatever floats your boat, I guess. Would this kids percent any different? Because I think that the age range for this has been like, I think I heard something from like nine to 15, 18.

I really don’t know. I you know, I haven’t seen that in the ER lately. We used to see Benadryl overdoses when parents were given Benadryl and they would give something else that had Benadryl with it for cold and stuff.

So, you know, that’s but that’s a different set up for the overdose. OK, but for the serotonin syndrome, the the basic science would be the same for a kid as it is for an adult. Yes.

Yeah. Really, the big thing is looking for the hyperreflexia and the clonus. OK.

I asked in the chat earlier, and I don’t know if you saw it, but with the clonus, do they usually present with one or the other as far as the oculus and the just like. No, you can have any or all of them. OK.

Yeah. So James asked, is there a statistical number on the cases? No, that’s the problem with it is that it’s I suspect that we probably don’t even think about it in the majority of the cases that we get or we just simply brush it off as though they’re anxious, things like that. So the problem is that there’s a wide spectrum.

It can be very, very mild symptoms that, you know, and I’m even thinking about just last night. You know, I had some folks that they were having nausea, vomiting, diarrhea, and they seem kind of anxious and stuff. You know, if I looked at their medication list a little closer, I might have said, maybe this is serotonin syndrome.

You know, we treated them symptomatically and gave them fluids and everything got better. So, you know, the but the problem is there is no real test for it. And so it’s always going to be a subjective diagnosis.

There’s until, you know, there is some test or something. And I don’t see that there ever will be one. I don’t think we’ll have a good number as far as, you know, what’s the incidence of this particular problem? Yeah.

And Michael, certainly those high doses and some of the patients where it’s given therapeutically, that’s a little bit easier for everyone to to manage. Yeah, there and Kimberly, yes, you’re right. There are some people that have even ocular clonus that’s chronic for them.

So but it’s a constellation of everything. So is is there hyperreflexia, is there clonus, is there elevated temperature, is there agitation? So all of these, it has to be a clinical spectrum. I don’t expect that you’re going to bring your your kid in with cerebral palsy and, you know, us, you know, you brought him in because he, you know, sprained an ankle or something.

And then we jump to that he has serotonin syndrome. But it is it is a constellation of symptoms that we have to look at. Yeah, well, OK, so, Michael, there’s the tricyclic antidepressants, they’re still out there.

Ellaville, especially is is still a popular antidepressant. And the TCA’s were notorious for for this where they would take a bottle of them. They would develop a severe acidosis.

And within a matter of an hour or two, they’re dead. And so, yeah, that, you know, for most part, most of the others antidepressants, if they overdose on those and you call poison control and you talk to them, they’re going to tell you that they just have to be observed for six hours. And if they start developing symptoms, they don’t they never have called it serotonin syndrome, but they will describe all the symptoms of serotonin syndrome.

Then they they will say, you know, call us back if you start having any of these symptoms or, you know, they need to be admitted or they need to be in the ICU, those sort of things. But yeah, they’re the antidepressants in general are are hard because the people need them. But at the same time, once they start feeling better, sometimes then they do try to take their life.

And now you’ve given them basically a gun that’s loaded and told them that this is their therapy. So, yeah, it’s it’s hard. It’s one reason that I would not want to be a psychiatrist.

One of many. Anything else? I appreciate everyone coming on and listening to me blather for a while and look forward to seeing all of you down the road. All right.

Well, we’ll go ahead and let’s see. How long do symptoms build up before it’s an ER situation? That’s actually nobody really has a good question or a good answer for that, because too often it may not even come in. And, you know, and sometimes it may be there for hours and may be there for minutes.

So you never know. And also if they go down. So let’s the the first one of these that I probably saw was a roofer that was doing cocaine and meth while he was up on a on a roof in Texas in the summertime and his temperature was one hundred and eight.

And so, you know, which one came first? And then the next thing is how long until he was found after he apparently was he was found on the ground beside the building? They don’t know if he fell or not. You know, so how long had he been on the ground? And, you know, did he have some of the symptoms while he was still up on the roof and then he climbed down? Did he fall down? You know, that’s that’s the issue. Nobody really knows where to paint the start line for this, because there’s such a wide variation in how it can present.

It’s an excellent question, though. I just wish I had an answer for it, but I don’t. Does alcohol have anything to do with it as well? Yeah, I did not see anything that said that alcohol is going to make this more or less likely.

You know, we certainly see a lot of people drinking while they’re taking these drugs. And I don’t I’ve never seen anything that says that it’s a precipitating factor. So I think I just are slurring the words more, you know, that probably didn’t really have much to to do with it.

It’s a good question, though. And if and if you are researching this later and you come across something that, you know, that says something different than what I’ve said, please send it to me. I want to I want to look at it because it’s one of those I don’t think about as often as I should as well.

That’s that’s another reason why I’m presenting it tonight is because I think that we all miss it sometimes. Yeah, Cassidy, definitely. I I can’t tell you how many times I’ve sat in here, just like that doctor in that conference that at the end of the lecture stood up to go and make a phone call.

You know, I I sit here and I’m looking in my mind at the last four shifts that I had thinking, I wonder if that was part of what was their problem. So, yeah. And and believe me, if you if you came up to most ER doctors and you said, you know, could this be serotonin syndrome? Yeah, I think that you might end up with some doctors scratching their head going either.

What is that? Which was the typical response for years all the way up to, oh, my gosh, I’m glad that you brought that up. So, you know, please, if if there’s one thing that I really would like for for every EMS person to know is, you know, the doctors are are people just like you are. They’re not any better or any worse than anyone else.

And, you know, for the most part, we want to be reminded of some of these things. You know, put it in the back of our minds so that so that we can can think about it. Yeah, you’re going to have some that are going to be arrogant and they’re going to be jerks about it.

No. Yeah. What are you trying to tell me? Those are going to happen every every place that you go.

But hopefully it’s not as often as it used to be. So, yeah, I if you if you bring me a patient and you think about it, I want you to tell me. Excellent.

Anything else? All right. Well, everyone have a good night. Stay safe.

Get some good sleep. And we will see you at the next one. Bye bye.