Examkin

Question

Difficulty: MediumPharmacologic Interventions

A 28-year-old woman is brought to the emergency department by her roommate due to severe agitation, confusion, and muscle twitching that began earlier today. She has a history of major depressive disorder, for which she takes citalopram. Two days ago, she was evaluated at an urgent care clinic for a severe migraine and was prescribed sumatriptan. Today, she also consumed multiple doses of over-the-counter dextromethorphan for a new-onset cough.

On arrival, her temperature is 39.2∘C39.2^\circ\text{C} (102.6∘F102.6^\circ\text{F}), blood pressure is 168/98 mmHg168/98\text{ mmHg}, pulse is 128/min128/\text{min}, and respiratory rate is 22/min22/\text{min}. Physical examination reveals a diaphoretic, flushed, and restless patient. Pupils are 6 mm6\text{ mm} and reactive to light bilaterally. Bowel sounds are hyperactive. Neurologic examination is notable for spontaneous myoclonus, hyperreflexia that is more pronounced in the lower extremities, and ocular clonus.

Which of the following pharmacologic interventions are appropriate in the initial management of this patient? (Select all that apply)

  1. Discontinue the patient's current citalopram prescriptionAnswer
  2. Administer intravenous lorazepamAnswer
  3. C
    Administer intravenous fentanyl for shivering and discomfort
  4. D
    Administer intravenous haloperidol for acute agitation
  5. E
    Administer oral bromocriptine

Answer

The appropriate initial interventions are to discontinue the patient's current citalopram prescription and administer intravenous lorazepam.
This patient is presenting with classic signs of serotonin syndrome, precipitated by the concurrent use of citalopram (an SSRI), sumatriptan (a 5-HT receptor agonist), and dextromethorphan (which possesses serotonin reuptake inhibition properties). Serotonin syndrome is characterized by a clinical triad of altered mental status, autonomic hyperactivity, and neuromuscular abnormalities (which are typically more pronounced in the lower extremities). The most critical initial intervention is the immediate discontinuation of all serotonergic medications. Furthermore, intravenous benzodiazepines, such as lorazepam, are the primary pharmacologic therapy for symptomatic control. They effectively reduce agitation, blunt the hyperadrenergic autonomic response (thereby lowering heart rate and blood pressure), and decrease excessive muscle hyperactivity, which helps mitigate hyperthermia.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and medication history.
The patient is experiencing altered mental status, autonomic hyperactivity (tachycardia, hyperthermia, diaphoresis, hyperactive bowel sounds), and neuromuscular excitation (hyperreflexia, myoclonus, ocular clonus) after taking citalopram, sumatriptan, and dextromethorphan.
Identifying the clinical triad in the context of multiple serotonergic agents confirms the diagnosis of serotonin syndrome.
2
Determine the priority interventions based on the identified toxidrome.
The primary treatments are discontinuing the offending agents (citalopram, sumatriptan, dextromethorphan) and providing supportive care with sedation.
Removing the trigger halts the pathophysiologic cascade, while sedation mitigates the life-threatening autonomic and neuromuscular symptoms.
3
Select the appropriate pharmacologic agents for symptomatic control.
Intravenous benzodiazepines, such as lorazepam, are selected to control agitation and muscle hyperactivity.
Benzodiazepines safely reduce the hyperadrenergic state without interacting with the serotonin pathways or worsening hyperthermia.

Key Concept

The initial management of serotonin syndrome requires the immediate discontinuation of all serotonergic agents and the administration of benzodiazepines for the symptomatic control of agitation, hyperthermia, and neuromuscular hyperactivity.
Rate this question

Topics

Pharmacologic Interventions

More questions from this topic