A 32-year-old woman is brought to the emergency department by her husband for new-onset "shaking spells" and high anxiety. She is a yoga teacher and has a history of chronic back pain, generalized anxiety disorder, and dysthymia. Her current medications include venlafaxine, ibuprofen, and tramadol. Her husband says that she recently began taking St. John's wort for depression.
Her temperature is 38.3 C (101 F), blood pressure is 160/90 mm Hg, and pulse is 144/min. On examination, her voice is tremulous, and there are tremors in her lower extremities. The patient is flushed and diaphoretic. Lower-extremity and ocular clonus is present. Mild rigidity is noted in the lower extremities. Left foot and patellar deep-tendon reflexes are 4+ and 3+, respectively.
Which of the following is the most appropriate next step in management of this patient?

Question

A 32-year-old woman is brought to the emergency department by her husband for new-onset "shaking spells" and high anxiety.  She is a yoga teacher and has a history of chronic back pain, generalized anxiety disorder, and dysthymia.  Her current medications include venlafaxine, ibuprofen, and tramadol.  Her husband says that she recently began taking St. John's wort for depression.
Her temperature is 38.3 C (101 F), blood pressure is 160/90 mm Hg, and pulse is 144/min.  On examination, her voice is tremulous, and there are tremors in her lower extremities.  The patient is flushed and diaphoretic.  Lower-extremity and ocular clonus is present.  Mild rigidity is noted in the lower extremities.  Left foot and patellar deep-tendon reflexes are 4+ and 3+, respectively.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9669_db54_853d_1580a2836fbf_MD0002_00 This patient exhibits signs and symptoms consistent with serotonin syndrome, a potentially dangerous condition associated with excess serotonergic activity in the central nervous system. Serotonin syndrome is usually caused by inadvertent interactions between drugs, therapeutic use of multiple serotonergic agents, or overdose on serotonergic medications. This patient is taking multiple medications with serotonergic activity, including St. John's wort, venlafaxine (serotonin-norepinephrine reuptake inhibitor), and tramadol. No tests confirm the diagnosis of serotonin syndrome, which is made based on medication history and clinical findings. Symptoms include a classic triad of mental status changes (eg, anxiety, delirium, confusion, restlessness), autonomic dysregulation (eg, diaphoresis, tachycardia, hypertension, hyperthermia, diarrhea, mydriasis), and neuromuscular hyperactivity (eg, hyperreflexia, tremor, rigidity, myoclonus, ocular clonus, bilateral Babinski signs). First-line treatment includes removal of precipitating drugs, supportive care (eg, hydration), and benzodiazepines. Failure of symptoms to resolve or onset of more severe symptoms (eg, hyperthermia, disorientation) may require the use of cyproheptadine, a serotonin antagonist. (Choices A and D) If the diagnosis is unclear and symptoms are severe, CT scan can be helpful to evaluate for intracranial bleeding or mass, and lumbar puncture can help rule out meningitis. However, this patient's presentation is highly suggestive of serotonin syndrome, and further diagnostic procedures are not necessary at this time. (Choice B) Electroencephalogram (EEG) is typically used to determine whether seizure activity is occurring. During seizure activity, the EEG typically displays a characteristic synchronous spike-and-wave pattern followed by postictal suppression. Seizure activity involves episodes of tonic-clonic movements followed by a postictal state, but this patient has no tonic movements associated with her clonus and does not appear postictal, lowering clinical suspicion for seizures. (Choice E) No laboratory tests confirm the diagnosis of serotonin syndrome, as serum serotonin levels do not correlate with clinical findings in this condition. Checking serotonin levels would be indicated in a condition such as carcinoid syndrome. Educational objective: Serotonin syndrome is caused by excess serotonergic activity, most commonly due to drug-drug interactions or use of multiple serotonergic medications. It consists of mental status changes, autonomic dysregulation, and neuromuscular hyperactivity. Initial management includes benzodiazepines and supportive measures. __________ References: Treatment of four psychiatric emergencies in the intensive care unit. (http://www.ncbi.nlm.nih.gov/pubmed/22732295)

A 32-Year-Old Woman Is Brought to the Emergency Department by Her