Serotonin Sylvia — Serotonin Syndrome
Two serotonergic drugs, then agitation, clonus and a 102°F fever — stop both now
Sylvia takes her daily sertraline and is prescribed tramadol for back pain by an urgent care provider who doesn't know her medication list. Within six hours she is agitated, drenched in sweat, and her legs jerk rhythmically when the nurse checks her reflexes.
Sylvia started a new pain medication while already taking her SSRI and, within hours, becomes agitated, sweaty and shaky. Serotonin syndrome results from combining serotonergic drugs (SSRIs, SNRIs, MAOIs, tramadol, triptans) and presents with a classic triad of mental status changes, autonomic instability and neuromuscular abnormalities like clonus and hyperreflexia. It develops rapidly, within hours of the interacting dose, and is managed by stopping all serotonergic agents and providing supportive care.
Read Serotonin Sylvia's full story →The story arc
The setup
Sylvia has taken sertraline for depression for two years and is given tramadol for acute back pain without a medication reconciliation.
The turn
Within a few hours she feels anxious and restless, her heart races, and she starts sweating heavily despite a cool room.
The crisis
Her temperature rises to 102.2°F, her legs show rhythmic clonus, deep tendon reflexes are hyperactive, and she becomes confused.
The save
The nurse stops both serotonergic medications, notifies the provider, gives IV fluids and cooling measures, and prepares for cyproheptadine if symptoms are severe.
NCLEX study section — Serotonin Syndrome
What this chapter is testing: the recognition cues, the numbers and the priority action.
Study section: Mental Health
Take this chapter into practice questions on the same topic.