Discontinue all serotonergic drugs
Aggressive supportive care
If pressors required, direct acting (e.g. norepinephrine, epi) preferred, MAO inhibition causes erratic response to dopamine
Benzos
Goal is to eliminate agitation, neuromuscular abnormalities, elevations in HR/BP
In severe cases, large doses are required (diazepam IV 10-20 mg, titrated with 10 mg increments)
Cyproheptadine
Give if benzodiazepines and supportive care fail to improve agitation and abnormal vitals<unk>  antagonist
Also has antihistamine and anticholinergic properties that may exacerbate other mixed toxicology picture
Give 12mg PO/NG; repeat with 2mg q2hr until clinical response is seen (max 32mg/d)
Give 4mg q6hr x48hr if patient is responsive to initial dose
Chlorpromazine
Phenothiazine with antiserotonergic effects
50mg to 100mg IM
Avoid in:
Hemodynamically unstable patients as can cause serious hypotension
Cases in which NMS may still be on the differential
Dexmedetomidine
Small case series found this helpful in adolescent cases refractory to benzos
Dantrolene generally not recommended as it can worsen<unk>  toxicity
Treat hyperthermia
Hyperthermia due to increase in muscular activity, not change in set point
Intubate and paralyze if temperature > 41.1
Standard cooling measures
Fans, water sprays, ice packs, cooled crystalloids, cooling blankets
If pressors required, direct acting (e.g. norepinephrine, epi) preferred, MAO inhibition causes erratic response to dopamine
Goal is to eliminate agitation, neuromuscular abnormalities, elevations in HR/BP
In severe cases, large doses are required (diazepam IV 10-20 mg, titrated with 10 mg increments)
Give if benzodiazepines and supportive care fail to improve agitation and abnormal vitals<unk>  antagonist
Also has antihistamine and anticholinergic properties that may exacerbate other mixed toxicology picture
Give 12mg PO/NG; repeat with 2mg q2hr until clinical response is seen (max 32mg/d)
Give 4mg q6hr x48hr if patient is responsive to initial dose
Also has antihistamine and anticholinergic properties that may exacerbate other mixed toxicology picture
Phenothiazine with antiserotonergic effects
50mg to 100mg IM
Avoid in:
Hemodynamically unstable patients as can cause serious hypotension
Cases in which NMS may still be on the differential
Hemodynamically unstable patients as can cause serious hypotension
Cases in which NMS may still be on the differential
Small case series found this helpful in adolescent cases refractory to benzos
Hyperthermia due to increase in muscular activity, not change in set point
Intubate and paralyze if temperature > 41.1
Standard cooling measures
Fans, water sprays, ice packs, cooled crystalloids, cooling blankets
Fans, water sprays, ice packs, cooled crystalloids, cooling blankets
Serotonin syndrome
Chorea
Cannabinoid hyperemesis syndrome
Sydenham's chorea
Cholinergic crisis
Neuroleptic malignant syndrome
Cocaine toxicity
Anticholinergic toxicity