Fast Five Quiz: Serotonin Syndrome

Richard H. Sinert, DO


June 04, 2021

Once serotonin syndrome has been diagnosed and the offending agent has been removed, supportive care is the mainstay of treatment. The syndrome often resolves within 24 hours after discontinuation of the serotoninergic agent and initiation of supportive care. More often than not, these patients will need intensive care unit monitoring, including the following:

  • Oxygen administration

  • Intravenous fluids

  • Continuous cardiac monitoring (including QTc and QRS duration monitoring)

  • Airway support/intubation

In the setting of recent ingestion, the use of activated charcoal to assist with gastrointestinal decontamination may be considered.

One of the most important components of treatment is administration of benzodiazepines, which can alleviate numerous symptoms, especially agitation.

If the patient is hyperthermic (especially with a temperature > 40 °C), it is important to begin active external cooling. Because the rise in temperature is of muscular origin, antipyretics are of no use, and paralytics are indicated when fever is high.

For both hemodynamic instability and agitation, some evidence suggests that dexmedetomidine may be useful to treat these symptoms of serotonin toxicity.

For severe hypertension, easily titratable medications (eg, clevidipine or esmolol) should be used. In cases of refractory hypotension, vasopressors should be used.

The serotonin antagonist cyproheptadine has been recommended for the treatment of serotonin syndrome. Mirtazapine, a 5-HT3 and 5-HT2 antagonist, has also been used in a small number of cases; however, multiple studies have suggested that this agent does not change outcomes.

Although many different agents have been used in the care of patients with serotonin syndrome, there are several that are not recommended, including olanzapine, chlorpromazine, propranolol, bromocriptine, and dantrolene.

Read more about the management of serotonin syndrome.

This Fast Five Quiz was excerpted and adapted from the Medscape Drugs & Diseases article Serotonin Syndrome.

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