A 19-year-old male college student is brought to the emergency department by his roommate … — USMLE Step 2 CK

A $19$ -year-old male college student is brought to the emergency department by his roommate due to bizarre behavior and severe agitation over the past $24$ hours. The roommate reports that the patient has been barricading the door, claiming that hidden cameras are recording him. The patient has a history of major depressive disorder, for which he takes citalopram. He recently developed a mild upper respiratory infection and has been drinking multiple bottles of over-the-counter cough syrup daily to experience a "euphoric high." Temperature is $38.6^\circ\text{C}$ ( $101.5^\circ\text{F}$ ), pulse is $126/\text{min}$ , respirations are $22/\text{min}$ , and blood pressure is $155/95\text{ mm Hg}$ . Physical examination reveals a profusely diaphoretic, tremulous young man. Neurologic examination demonstrates bilateral hyperreflexia and prominent spontaneous clonus in the lower extremities. Which of the following is the most appropriate next step in the management of this patient?

Discontinuation of citalopram and administration of intravenous lorazepamCevap
B
Continuation of citalopram and administration of intramuscular haloperidol
C
Administration of intravenous ceftriaxone and vancomycin
D
Diagnosis of schizophreniform disorder and inpatient psychiatric admission
E
Immediate disclosure of the patient's substance abuse to his parents

Cevap

Discontinuation of citalopram and administration of intravenous lorazepam

The correct answer correctly identifies the primary acute management for Serotonin Syndrome. This patient's presentation of autonomic instability (tachycardia, hypertension, hyperthermia), altered mental status (paranoia, agitation), and prominent neuromuscular hyperactivity (bilateral hyperreflexia, spontaneous clonus) is the hallmark triad of Serotonin Syndrome. This life-threatening condition was precipitated by the combination of his prescribed citalopram (an SSRI) and the abuse of dextromethorphan, which has strong serotonin reuptake inhibition properties. Immediate management requires discontinuing all serotonergic agents and initiating supportive care with intravenous benzodiazepines (e.g., lorazepam) to control agitation, reduce muscle rigidity, and lower body temperature.

Adım Adım Çözüm

Identify the primary toxidrome based on the patient's clinical presentation.

The patient has the classic triad of autonomic instability (fever, tachycardia, hypertension), altered mental status (agitation, paranoia), and neuromuscular hyperactivity (hyperreflexia, spontaneous clonus).

Recognizing these specific neurological and autonomic signs is essential for diagnosing Serotonin Syndrome, distinguishing it from primary psychiatric emergencies.

Determine the pharmacological etiology of the toxidrome.

The syndrome was precipitated by the concurrent use of citalopram (a prescribed SSRI) and massive doses of dextromethorphan (an abused over-the-counter cough syrup).

Dextromethorphan has potent serotonin reuptake inhibition properties. When abused in high doses by a patient already on serotonergic medication, it triggers severe serotonin toxicity.

Select the most appropriate acute management for Serotonin Syndrome.

The immediate next step is the discontinuation of all serotonergic agents and administration of supportive care, including intravenous benzodiazepines.

Benzodiazepines (like lorazepam) are the mainstay of treatment to control agitation, reduce muscle contraction, and thereby lower body temperature and blood pressure.

Anahtar Kavram

Serotonin syndrome is a life-threatening toxidrome characterized by autonomic instability, altered mental status, and neuromuscular hyperactivity (especially clonus). It is often triggered by interactions between SSRIs and substances of abuse like high-dose dextromethorphan. First-line management is discontinuing serotonergic agents and administering benzodiazepines.

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