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Serotonin Syndrome: High-Yield Pearls Every Clinician Should Know · Pearls and Prep

• 0:00
  Foreign.
• 0:06
  Welcome
• 0:06
  back,
• 0:07
  my
• 0:07
  friends,
• 0:07
  to
• 0:07
  another
• 0:08
  great
• 0:09
  episode
• 0:09
  of
• 0:10
  Pearls
• 0:10
  and
• 0:11
  Prep
• 0:11
  npz.
• 0:12
  Here,
• 0:12
  your
• 0:13
  preceptor
• 0:13
  in
• 0:14
  your
• 0:14
  pocket.
• 0:14
  We're
• 0:15
  going
• 0:15
  to
• 0:15
  keep
• 0:15
  you
• 0:15
  fresh,
• 0:16
  we're
• 0:16
  going
• 0:16
  to
• 0:16
  keep
• 0:17
  you
• 0:17
  prepped
• 0:17
  for
• 0:18
  practice
• 0:18
  today
• 0:19
  and
• 0:19
  we're
• 0:19
  going
• 0:20
  to
• 0:20
  go
• 0:20
  over
• 0:20
  a
• 0:20
  case
• 0:20
  study
• 0:21
  that
• 0:22
  I
• 0:22
  think
• 0:22
  is
• 0:22
  super
• 0:23
  high
• 0:23
  yield
• 0:23
  and
• 0:24
  gets
• 0:24
  right
• 0:24
  to
• 0:25
  the
• 0:25
  point.
• 0:25
  Today
• 0:26
  we
• 0:26
  have
• 0:27
  a
• 0:27
  49
• 0:27
  year
• 0:28
  old
• 0:28
  mock
• 0:28
  patient.
• 0:29
  We'll
• 0:29
  call
• 0:29
  him
• 0:29
  Dale.
• 0:30
  He
• 0:31
  presents
• 0:31
  in
• 0:32
  the
• 0:32
  emergency
• 0:32
  room
• 0:33
  with
• 0:33
  altered
• 0:34
  mental
• 0:34
  status,
• 0:35
  muscle
• 0:35
  rigidity
• 0:36
  and
• 0:36
  hyperthermia.
• 0:38
  He
• 0:38
  recently
• 0:39
  increased
• 0:40
  his
• 0:40
  Zoloft
• 0:41
  to
• 0:41
  a
• 0:41
  hundred
• 0:42
  milligrams
• 0:43
  a
• 0:43
  day
• 0:44
  and
• 0:44
  he
• 0:45
  has
• 0:45
  some
• 0:45
  depression.
• 0:46
  And
• 0:47
  recently
• 0:47
  he's
• 0:48
  also
• 0:48
  been
• 0:48
  dealing
• 0:49
  with
• 0:49
  some
• 0:49
  chronic
• 0:50
  pain
• 0:50
  medication
• 0:50
  changes.
• 0:51
  And
• 0:52
  his
• 0:52
  a
• 0:53
  Prescriber
• 0:53
  added
• 0:54
  tramadol,
• 0:54
  50
• 0:55
  milligrams
• 0:55
  twice
• 0:56
  daily
• 0:56
  in
• 0:57
  the
• 0:57
  past
• 0:57
  24
• 0:58
  hours.
• 0:58
  His
• 0:58
  family
• 0:59
  has
• 0:59
  noticed
• 1:00
  he's
• 1:00
  been
• 1:00
  a
• 1:00
  little
• 1:00
  confused
• 1:01
  and
• 1:01
  sweating
• 1:02
  a
• 1:02
  lot
• 1:02
  and
• 1:02
  had
• 1:02
  some
• 1:03
  tremors.
• 1:03
  On
• 1:04
  examination
• 1:05
  you
• 1:05
  notice
• 1:05
  he
• 1:06
  has
• 1:06
  a
• 1:06
  temperature
• 1:06
  of
• 1:06
  102.6.
• 1:08
  His
• 1:08
  heart
• 1:08
  rate
• 1:08
  is
• 1:08
  118.
• 1:09
  His
• 1:10
  blood
• 1:10
  pressure
• 1:10
  is
• 1:10
  158
• 1:11
  over
• 1:11
  94
• 1:12
  and
• 1:12
  his
• 1:12
  respiratory
• 1:12
  rate
• 1:13
  is
• 1:13
  24.
• 1:14
  He's
• 1:14
  pretty
• 1:14
  agitated.
• 1:15
  He's
• 1:15
  a
• 1:15
  little
• 1:16
  bit
• 1:16
  disoriented.
• 1:17
  You
• 1:17
  do
• 1:18
  a
• 1:18
  neuromuscular
• 1:19
  examination
• 1:20
  and
• 1:20
  you
• 1:20
  notice
• 1:20
  that
• 1:21
  there's.
• 1:21
  The
• 1:21
  patient
• 1:21
  demonstrates
• 1:22
  spontaneous
• 1:23
  clonus
• 1:23
  in
• 1:24
  his
• 1:24
  lower
• 1:25
  extremities.
• 1:26
  Hyperreflexia.
• 1:27
  And
• 1:28
  you
• 1:28
  see
• 1:28
  again
• 1:28
  that
• 1:29
  he's
• 1:29
  sweating
• 1:29
  profusely.
• 1:30
  He's
• 1:30
  markedly
• 1:31
  diaphoretic.
• 1:32
  Okay,
• 1:33
  so
• 1:34
  what's
• 1:34
  going
• 1:34
  on
• 1:35
  here?
• 1:35
  What
• 1:35
  are
• 1:35
  you
• 1:36
  thinking?
• 1:36
  If
• 1:36
  you
• 1:37
  wanted
• 1:37
  to
• 1:37
  debate
• 1:38
  this
• 1:38
  with
• 1:38
  your
• 1:39
  classmates
• 1:40
  and
• 1:41
  figure
• 1:41
  out
• 1:41
  what's
• 1:41
  going
• 1:41
  on,
• 1:42
  you
• 1:42
  have
• 1:42
  some
• 1:42
  information
• 1:43
  here.
• 1:43
  You
• 1:43
  have
• 1:43
  a
• 1:43
  couple
• 1:44
  medications
• 1:45
  that
• 1:45
  you
• 1:45
  can
• 1:45
  mull
• 1:46
  over
• 1:46
  and
• 1:46
  you
• 1:46
  have
• 1:47
  a,
• 1:47
  A,
• 1:47
  a
• 1:47
  very
• 1:47
  physical
• 1:48
  response
• 1:49
  here,
• 1:49
  right?
• 1:49
  This
• 1:49
  seems
• 1:50
  to
• 1:50
  be
• 1:50
  a
• 1:51
  textbook
• 1:52
  presentation
• 1:52
  of
• 1:53
  something
• 1:53
  very
• 1:54
  specific.
• 1:55
  Right?
• 1:55
  You
• 1:55
  have
• 1:55
  altered
• 1:56
  mental
• 1:56
  status,
• 1:57
  hyperreflexia.
• 1:58
  You
• 1:58
  have
• 1:58
  spontaneous
• 1:59
  clonus.
• 2:00
  So
• 2:00
  something's
• 2:01
  going
• 2:01
  on
• 2:01
  here.
• 2:02
  The
• 2:02
  vital
• 2:02
  signs
• 2:03
  are
• 2:03
  definitely
• 2:05
  out
• 2:05
  of
• 2:05
  whack.
• 2:05
  We
• 2:06
  have
• 2:06
  elevated
• 2:06
  vital
• 2:07
  signs
• 2:07
  across
• 2:07
  the
• 2:08
  board.
• 2:09
  And
• 2:09
  of
• 2:09
  all
• 2:09
  the
• 2:10
  medication
• 2:10
  we
• 2:11
  see,
• 2:11
  Zoloft
• 2:12
  has
• 2:12
  been
• 2:12
  increased.
• 2:12
  And
• 2:12
  we
• 2:12
  also
• 2:13
  have
• 2:13
  tramadol
• 2:14
  on
• 2:14
  board
• 2:15
  to
• 2:15
  keep
• 2:15
  things
• 2:16
  easier
• 2:16
  for
• 2:17
  NP
• 2:17
  students
• 2:18
  out
• 2:18
  there.
• 2:19
  If
• 2:19
  you're
• 2:19
  new
• 2:19
  to
• 2:19
  this
• 2:20
  lingo
• 2:20
  and
• 2:21
  these
• 2:21
  case
• 2:21
  studies
• 2:22
  and
• 2:23
  you're.
• 2:23
  It's
• 2:23
  all
• 2:24
  one
• 2:24
  blur
• 2:24
  to
• 2:24
  you
• 2:24
  and
• 2:24
  you're
• 2:25
  not
• 2:25
  sure
• 2:25
  the
• 2:25
  difference
• 2:25
  between
• 2:26
  serotonin
• 2:26
  syndrome
• 2:27
  and
• 2:27
  NMS
• 2:28
  or
• 2:28
  neuroleptic
• 2:29
  malignant
• 2:29
  syndrome,
• 2:31
  remember
• 2:31
  that
• 2:31
  with
• 2:31
  NMS
• 2:32
  we're
• 2:32
  talking
• 2:32
  antipsychotics.
• 2:34
  With
• 2:34
  serotonin
• 2:35
  syndrome,
• 2:35
  we're
• 2:35
  talking
• 2:35
  about
• 2:36
  serotonin.
• 2:37
  Okay?
• 2:38
  And
• 2:38
  so
• 2:39
  the
• 2:39
  clue
• 2:40
  is
• 2:40
  right.
• 2:41
  In
• 2:41
  the
• 2:41
  case
• 2:41
  study,
• 2:42
  it's
• 2:42
  not
• 2:42
  a
• 2:42
  trick
• 2:43
  question.
• 2:43
  Nobody's
• 2:44
  out
• 2:44
  to
• 2:44
  trick
• 2:45
  you.
• 2:45
  This
• 2:46
  is
• 2:46
  bread
• 2:47
  and
• 2:47
  butter.
• 2:47
  Serotonin
• 2:48
  syndrome.
• 2:49
  The
• 2:49
  elevated
• 2:49
  vital
• 2:50
  signs,
• 2:50
  the
• 2:50
  altered
• 2:51
  mental
• 2:51
  status,
• 2:51
  the
• 2:52
  muscle
• 2:52
  rigidity,
• 2:53
  diaphoresis,
• 2:54
  and
• 2:55
  so
• 2:55
  it's
• 2:56
  all
• 2:56
  right
• 2:56
  in
• 2:57
  front
• 2:57
  of
• 2:57
  you.
• 2:57
  And
• 2:57
  for
• 2:57
  serotonin
• 2:58
  syndrome,
• 2:59
  my
• 2:59
  friends,
• 2:59
  it's
• 3:00
  a
• 3:00
  very
• 3:00
  clinical
• 3:01
  diagnosis.
• 3:01
  It's
• 3:01
  not
• 3:02
  like
• 3:02
  you
• 3:02
  get
• 3:02
  a
• 3:02
  serum
• 3:03
  serotonin
• 3:04
  and
• 3:04
  you
• 3:04
  say,
• 3:04
  oh,
• 3:04
  my
• 3:04
  God,
• 3:05
  there's
• 3:05
  so
• 3:05
  much
• 3:05
  serotonin
• 3:06
  in
• 3:06
  the
• 3:06
  system.
• 3:07
  We
• 3:07
  have
• 3:07
  serotonin
• 3:08
  syndrome.
• 3:08
  It's
• 3:08
  not
• 3:08
  like
• 3:08
  that.
• 3:09
  It's
• 3:09
  a
• 3:09
  very
• 3:09
  clinical
• 3:10
  diagnosis.
• 3:11
  So
• 3:11
  you're
• 3:11
  looking
• 3:11
  for
• 3:11
  clusters
• 3:12
  of
• 3:13
  symptoms
• 3:13
  that
• 3:14
  are
• 3:14
  very
• 3:14
  specific
• 3:15
  and
• 3:15
  follow
• 3:16
  the
• 3:17
  increase
• 3:18
  or
• 3:19
  initiation
• 3:20
  or
• 3:20
  a
• 3:20
  combination
• 3:21
  of
• 3:21
  serotonergic
• 3:22
  agents.
• 3:22
  Right.
• 3:22
  It's
• 3:23
  almost
• 3:23
  always
• 3:23
  that
• 3:23
  case
• 3:24
  where
• 3:24
  there's
• 3:24
  a
• 3:24
  serotonergic
• 3:25
  agent
• 3:25
  that
• 3:26
  was
• 3:26
  just
• 3:26
  added,
• 3:26
  it's
• 3:26
  increased
• 3:27
  or
• 3:27
  combined
• 3:28
  with
• 3:28
  another
• 3:29
  serotonergic
• 3:30
  agent.
• 3:30
  This
• 3:31
  develops
• 3:31
  within
• 3:32
  hours.
• 3:32
  This
• 3:33
  is
• 3:33
  a
• 3:33
  very
• 3:33
  quick
• 3:34
  manifestation.
• 3:35
  And
• 3:35
  that
• 3:35
  also
• 3:36
  separates
• 3:36
  it
• 3:36
  from
• 3:37
  the
• 3:37
  other
• 3:38
  big
• 3:38
  scary
• 3:39
  syndromes,
• 3:39
  like
• 3:39
  neuroleptic
• 3:40
  malignant
• 3:41
  syndrome,
• 3:41
  which
• 3:42
  is
• 3:42
  different.
• 3:42
  It's
• 3:43
  days
• 3:43
  or
• 3:43
  weeks.
• 3:44
  With
• 3:44
  serotonin
• 3:45
  syndrome,
• 3:45
  we're
• 3:45
  talking
• 3:45
  about
• 3:46
  hours
• 3:46
  within
• 3:47
  hours
• 3:47
  of
• 3:47
  drug
• 3:48
  initiation,
• 3:48
  dose
• 3:49
  increase,
• 3:49
  or
• 3:49
  adding
• 3:50
  a
• 3:50
  second
• 3:50
  serotonergic
• 3:51
  agent.
• 3:52
  So
• 3:53
  again,
• 3:53
  here
• 3:53
  we
• 3:53
  have
• 3:54
  Tramadol.
• 3:54
  It
• 3:54
  is
• 3:54
  certainly
• 3:55
  capable
• 3:56
  of
• 3:57
  increasing
• 3:57
  the
• 3:57
  amount
• 3:57
  of
• 3:58
  serotonin
• 3:58
  in
• 3:58
  the
• 3:58
  synapse,
• 3:59
  releasing
• 4:00
  more
• 4:00
  serotonin.
• 4:01
  It's
• 4:01
  an
• 4:01
  offender.
• 4:02
  It's
• 4:02
  a
• 4:02
  usual
• 4:02
  offender.
• 4:03
  It's
• 4:03
  for
• 4:03
  pain.
• 4:04
  Not
• 4:04
  every
• 4:04
  patient
• 4:05
  is
• 4:05
  going
• 4:05
  to
• 4:05
  know
• 4:06
  that.
• 4:06
  You
• 4:07
  know,
• 4:07
  here
• 4:07
  they
• 4:07
  are
• 4:07
  on
• 4:07
  Zoloft,
• 4:08
  and
• 4:08
  weeks
• 4:09
  later
• 4:09
  they're
• 4:10
  dealing
• 4:10
  with
• 4:10
  chronic
• 4:11
  pain.
• 4:11
  The
• 4:11
  two
• 4:11
  medications
• 4:12
  feel
• 4:13
  different,
• 4:13
  sound
• 4:14
  different,
• 4:14
  look
• 4:14
  different.
• 4:15
  And
• 4:15
  there's
• 4:15
  no
• 4:15
  obvious
• 4:16
  reason
• 4:17
  that
• 4:17
  that
• 4:17
  patient
• 4:18
  or
• 4:18
  a
• 4:18
  provider
• 4:19
  who's
• 4:19
  not
• 4:19
  paying
• 4:19
  attention
• 4:20
  would
• 4:20
  think
• 4:21
  that
• 4:21
  there's
• 4:21
  any
• 4:21
  problem
• 4:22
  with
• 4:22
  that.
• 4:22
  And
• 4:23
  lo
• 4:23
  and
• 4:23
  behold,
• 4:24
  tramadol
• 4:24
  and
• 4:25
  Zoloft
• 4:26
  can
• 4:26
  certainly
• 4:27
  wreak
• 4:27
  havoc
• 4:27
  and
• 4:28
  manifest
• 4:28
  into
• 4:28
  these
• 4:29
  symptoms.
• 4:30
  So
• 4:31
  now
• 4:31
  what's
• 4:32
  happening?
• 4:32
  In
• 4:32
  serotonin
• 4:33
  syndrome?
• 4:33
  My
• 4:33
  friends,
• 4:34
  there's
• 4:34
  excess
• 4:35
  serotonergic
• 4:36
  activity
• 4:36
  in
• 4:36
  the
• 4:37
  central
• 4:37
  nervous
• 4:37
  system.
• 4:38
  We
• 4:38
  typically
• 4:39
  find
• 4:39
  this
• 4:39
  in
• 4:39
  an
• 4:39
  overdose.
• 4:40
  Right.
• 4:40
  Your
• 4:40
  patient
• 4:41
  overdoses
• 4:41
  on
• 4:41
  Zoloft
• 4:42
  or
• 4:42
  Effexor.
• 4:43
  And
• 4:43
  this
• 4:44
  cluster
• 4:44
  of
• 4:44
  symptoms
• 4:45
  can
• 4:45
  certainly
• 4:45
  become
• 4:45
  problematic.
• 4:46
  But
• 4:46
  please
• 4:47
  know,
• 4:47
  it
• 4:47
  doesn't
• 4:48
  take
• 4:48
  an
• 4:48
  overdose
• 4:49
  alone
• 4:50
  to
• 4:50
  cause
• 4:50
  these
• 4:50
  symptoms.
• 4:51
  Again,
• 4:51
  it
• 4:51
  can
• 4:51
  be
• 4:51
  initiation
• 4:53
  of
• 4:54
  a
• 4:54
  serotonergic
• 4:55
  agent
• 4:55
  or
• 4:56
  the
• 4:56
  combination
• 4:56
  of
• 4:57
  one.
• 4:57
  We
• 4:57
  see
• 4:57
  these
• 4:58
  in
• 4:58
  migraine
• 4:58
  medications,
• 4:59
  too,
• 4:59
  that
• 5:00
  can
• 5:00
  collide
• 5:01
  with
• 5:01
  our
• 5:02
  SSRIs
• 5:02
  or
• 5:02
  SNRIs
• 5:03
  and
• 5:04
  cause
• 5:04
  this,
• 5:05
  especially,
• 5:05
  I've
• 5:06
  seen,
• 5:06
  with
• 5:06
  dose
• 5:07
  increases.
• 5:07
  So
• 5:08
  here
• 5:08
  you
• 5:08
  are.
• 5:08
  Your
• 5:08
  increasing
• 5:09
  effects
• 5:09
  are,
• 5:10
  you
• 5:10
  know,
• 5:10
  from
• 5:11
  75
• 5:12
  to
• 5:12
  150.
• 5:13
  And
• 5:13
  the
• 5:13
  patient's
• 5:14
  also
• 5:14
  being
• 5:14
  treated
• 5:14
  for
• 5:14
  migraines
• 5:15
  or
• 5:15
  chronic
• 5:15
  pain.
• 5:16
  And
• 5:16
  boom,
• 5:16
  you
• 5:17
  have
• 5:17
  this
• 5:17
  serotonin
• 5:18
  syndrome
• 5:19
  problem.
• 5:20
  This
• 5:20
  is
• 5:20
  an
• 5:20
  overstimulation
• 5:21
  of
• 5:21
  serotonin
• 5:22
  receptors,
• 5:22
  particularly
• 5:23
  5HT2A
• 5:24
  receptors.
• 5:25
  And
• 5:25
  in
• 5:26
  this
• 5:26
  case,
• 5:26
  the
• 5:26
  Tramadol
• 5:27
  and
• 5:27
  the
• 5:27
  Zoloft
• 5:28
  have
• 5:28
  the
• 5:28
  synergistic
• 5:29
  effect
• 5:29
  of
• 5:29
  inhibiting
• 5:30
  serotonin
• 5:30
  reuptake.
• 5:31
  And
• 5:31
  tramadol
• 5:32
  will
• 5:32
  promote
• 5:32
  serotonin
• 5:33
  release.
• 5:34
  Dangerous
• 5:34
  synergy
• 5:35
  here.
• 5:35
  Very
• 5:36
  dangerous.
• 5:37
  Severe
• 5:37
  serotonin
• 5:38
  toxicity
• 5:38
  will
• 5:38
  most
• 5:39
  commonly
• 5:39
  occur
• 5:39
  with
• 5:40
  combinations
• 5:40
  of
• 5:41
  drugs
• 5:41
  acting
• 5:41
  at
• 5:42
  different
• 5:42
  sites.
• 5:42
  They
• 5:43
  will
• 5:43
  especially
• 5:43
  see
• 5:44
  this
• 5:44
  with
• 5:44
  MAOI
• 5:45
  inhibitors
• 5:45
  when
• 5:46
  they're
• 5:46
  combined
• 5:46
  with
• 5:46
  SSRIs.
• 5:47
  It's
• 5:47
  a
• 5:47
  big
• 5:47
  no
• 5:47
  no.
• 5:48
  Those
• 5:48
  combinations
• 5:49
  can
• 5:49
  be
• 5:49
  very
• 5:49
  problematic.
• 5:50
  So
• 5:50
  it's
• 5:51
  very
• 5:51
  important
• 5:51
  you're
• 5:51
  able
• 5:52
  to
• 5:52
  isolate
• 5:52
  this.
• 5:53
  The
• 5:53
  algorithm
• 5:54
  here
• 5:54
  is
• 5:55
  pretty
• 5:55
  straightforward.
• 5:56
  And
• 5:57
  at
• 5:57
  the
• 5:57
  very
• 5:57
  top
• 5:57
  of
• 5:58
  the
• 5:58
  algorithm
• 5:58
  is,
• 5:59
  has
• 5:59
  a
• 6:00
  serotonergic
• 6:00
  agent
• 6:01
  been
• 6:01
  administered
• 6:01
  in
• 6:01
  the
• 6:02
  past
• 6:02
  five
• 6:02
  weeks?
• 6:02
  Just
• 6:03
  asking
• 6:03
  that
• 6:03
  question.
• 6:03
  When
• 6:04
  you
• 6:04
  have
• 6:04
  a
• 6:04
  patient
• 6:05
  in
• 6:05
  front
• 6:05
  of
• 6:05
  you
• 6:05
  with
• 6:06
  this
• 6:06
  constellation
• 6:06
  of
• 6:07
  symptoms,
• 6:07
  we
• 6:08
  want
• 6:08
  to
• 6:08
  get
• 6:08
  to
• 6:09
  the
• 6:09
  root
• 6:09
  of
• 6:09
  it
• 6:09
  and
• 6:09
  figure
• 6:10
  out,
• 6:10
  are
• 6:10
  we
• 6:11
  talking
• 6:11
  about
• 6:11
  serotonin
• 6:12
  or
• 6:12
  are
• 6:12
  we
• 6:12
  talking
• 6:13
  about
• 6:13
  an
• 6:13
  antipsychotic?
• 6:14
  Right.
• 6:14
  And
• 6:14
  that's
• 6:15
  going
• 6:15
  to
• 6:15
  involve
• 6:15
  a
• 6:15
  different
• 6:15
  decision
• 6:16
  tree
• 6:16
  for
• 6:17
  the
• 6:17
  antipsychotic
• 6:17
  versus
• 6:18
  the
• 6:18
  serotonergic
• 6:19
  medications.
• 6:19
  And
• 6:20
  remember,
• 6:20
  when
• 6:20
  it
• 6:21
  comes
• 6:21
  to
• 6:21
  serotonergic
• 6:22
  medications,
• 6:22
  you're
• 6:22
  not
• 6:22
  just
• 6:23
  hunting
• 6:23
  for
• 6:23
  SSRIs.
• 6:24
  There's
• 6:25
  going
• 6:25
  to
• 6:25
  be
• 6:25
  a
• 6:25
  list
• 6:25
  of
• 6:25
  other
• 6:26
  medications
• 6:26
  that
• 6:26
  can
• 6:27
  induce
• 6:27
  serotonin
• 6:27
  syndrome.
• 6:28
  So
• 6:28
  you
• 6:29
  go
• 6:29
  down
• 6:29
  the
• 6:29
  algorithm.
• 6:30
  You
• 6:30
  sure
• 6:30
  enough,
• 6:31
  a
• 6:31
  patient
• 6:31
  is
• 6:32
  on
• 6:32
  a
• 6:32
  serotonergic
• 6:33
  agent
• 6:33
  or
• 6:33
  two,
• 6:33
  he
• 6:34
  or
• 6:34
  she
• 6:34
  had
• 6:35
  increased
• 6:35
  the
• 6:36
  dose
• 6:36
  of
• 6:36
  those
• 6:36
  agents.
• 6:37
  And
• 6:37
  then
• 6:38
  you
• 6:38
  gotta
• 6:38
  ask
• 6:38
  yourself
• 6:39
  in
• 6:39
  the
• 6:39
  next
• 6:39
  part
• 6:40
  of
• 6:40
  the
• 6:40
  algorithm,
• 6:40
  are
• 6:41
  any
• 6:41
  of
• 6:41
  the
• 6:41
  following
• 6:42
  symptoms
• 6:42
  present?
• 6:43
  It
• 6:43
  would
• 6:43
  be
• 6:43
  like
• 6:43
  a
• 6:43
  tremor
• 6:44
  or
• 6:44
  hyperreflexia,
• 6:46
  spontaneous
• 6:46
  clonus,
• 6:47
  muscle
• 6:48
  rigidity
• 6:48
  or
• 6:49
  temperature
• 6:49
  greater
• 6:49
  than
• 6:50
  38
• 6:50
  Celsius.
• 6:51
  And
• 6:51
  you
• 6:51
  could
• 6:51
  see
• 6:51
  ocular
• 6:52
  clonus
• 6:52
  or
• 6:53
  inducible
• 6:53
  clonus.
• 6:54
  Now,
• 6:54
  when
• 6:54
  we're
• 6:54
  talking
• 6:55
  about
• 6:55
  clonus,
• 6:56
  we're
• 6:56
  talking
• 6:56
  about
• 6:57
  involuntary
• 6:58
  rhythmic
• 6:59
  pulsating,
• 6:59
  muscle
• 7:00
  contractions
• 7:01
  and
• 7:01
  relaxations.
• 7:03
  And
• 7:04
  you
• 7:04
  can
• 7:04
  induce
• 7:04
  clonus
• 7:05
  by
• 7:05
  dorsiflexing
• 7:06
  the
• 7:06
  foot.
• 7:07
  I
• 7:07
  highly
• 7:07
  encourage
• 7:08
  you
• 7:08
  to
• 7:08
  look
• 7:08
  at
• 7:08
  YouTube.
• 7:09
  There's
• 7:09
  a
• 7:09
  lot
• 7:10
  of
• 7:10
  really
• 7:10
  cool
• 7:10
  videos
• 7:11
  on
• 7:11
  this.
• 7:11
  And
• 7:11
  I'm
• 7:12
  a
• 7:12
  visual
• 7:12
  person.
• 7:12
  I
• 7:13
  feel
• 7:13
  very
• 7:13
  empowered
• 7:14
  when
• 7:14
  I
• 7:14
  look
• 7:15
  at
• 7:15
  videos
• 7:16
  because
• 7:16
  it
• 7:16
  allows
• 7:17
  me
• 7:17
  to
• 7:17
  be
• 7:18
  more
• 7:18
  confident
• 7:18
  if
• 7:18
  I
• 7:19
  ever
• 7:19
  have
• 7:19
  to
• 7:19
  see
• 7:19
  this
• 7:19
  in
• 7:20
  real
• 7:20
  time.
• 7:20
  Right.
• 7:21
  I'll
• 7:22
  include
• 7:22
  some
• 7:22
  YouTube
• 7:23
  links
• 7:23
  in
• 7:23
  the
• 7:24
  show
• 7:24
  notes.
• 7:25
  It's
• 7:25
  also
• 7:25
  a
• 7:25
  great
• 7:25
  time
• 7:26
  for
• 7:26
  you
• 7:26
  to
• 7:26
  become
• 7:26
  Patreon
• 7:27
  members
• 7:27
  in
• 7:27
  the
• 7:27
  show
• 7:28
  notes.
• 7:28
  Highly
• 7:28
  recommend
• 7:29
  it
• 7:29
  because
• 7:29
  we're
• 7:29
  going
• 7:29
  to
• 7:30
  have
• 7:30
  serotonin
• 7:30
  syndrome.
• 7:31
  Master
• 7:32
  handout
• 7:32
  for
• 7:32
  you.
• 7:33
  That's
• 7:33
  going
• 7:33
  to
• 7:33
  really
• 7:34
  help
• 7:34
  you
• 7:34
  with
• 7:34
  your
• 7:34
  board.
• 8:29
  It's
• 8:30
  really
• 8:30
  cool
• 8:30
  to
• 8:30
  see
• 8:30
  the
• 8:31
  ocular
• 8:31
  clonus
• 8:32
  and
• 8:32
  how
• 8:32
  the
• 7:38
  eyes
• 8:33
  wiggle
• 8:33
  left
• 8:33
  to
• 8:34
  right.
• 8:34
  It
• 8:34
  kind
• 8:34
  of
• 8:34
  looks
• 8:34
  like
• 8:34
  a
• 8:34
  nystagmus,
• 8:35
  but
• 8:36
  like
• 8:36
  on
• 8:36
  a
• 8:36
  caffeine
• 8:37
  high,
• 8:37
  the
• 8:37
  eyes
• 8:38
  are
• 8:38
  just
• 8:38
  really
• 8:38
  gyrating
• 8:39
  left
• 8:39
  to
• 8:39
  right,
• 8:40
  and
• 8:40
  you
• 8:40
  can
• 8:40
  see
• 8:41
  what
• 8:41
  the
• 8:42
  clonus
• 8:42
  looks
• 8:42
  like
• 8:43
  in
• 8:43
  the
• 8:43
  lower
• 8:43
  extremities.
• 8:44
  It's
• 8:45
  useful
• 8:45
  to
• 8:45
  see
• 8:45
  this
• 8:46
  with
• 8:46
  your
• 8:46
  own
• 8:46
  eyes
• 8:47
  so
• 8:47
  that
• 8:47
  when
• 8:47
  you
• 8:47
  see
• 8:47
  it
• 8:47
  clinically,
• 8:48
  you'll
• 8:48
  have
• 8:48
  a
• 8:48
  much
• 8:49
  better
• 8:49
  idea
• 8:49
  of
• 8:49
  what's
• 8:49
  going
• 8:50
  on.
• 8:50
  We're
• 8:50
  looking
• 8:51
  for
• 8:51
  muscle
• 8:51
  rigidity,
• 8:52
  just
• 8:52
  overall
• 8:52
  very
• 8:53
  rigid
• 8:53
  posture
• 8:54
  and
• 8:54
  tremors.
• 8:55
  Hyperreflexia.
• 8:57
  There's
• 8:57
  a
• 8:57
  diagnosis,
• 8:58
  it's
• 8:59
  based
• 8:59
  on
• 8:59
  the
• 8:59
  Hunter
• 8:59
  serotonin
• 9:00
  toxicity
• 9:01
  criteria,
• 9:02
  and
• 9:02
  it's
• 9:03
  a
• 9:03
  pretty
• 9:03
  specific
• 9:04
  diagnostic
• 9:05
  symptom.
• 9:05
  And
• 9:06
  it
• 9:06
  requires
• 9:06
  a
• 9:06
  serotonergic
• 9:07
  agent
• 9:07
  plus
• 9:08
  one
• 9:08
  of
• 9:08
  the
• 9:09
  following,
• 9:09
  which
• 9:09
  would
• 9:09
  be
• 9:09
  spontaneous
• 9:10
  clonus,
• 9:11
  like
• 9:11
  we
• 9:11
  talked
• 9:11
  about,
• 9:12
  inducible
• 9:12
  clonus.
• 9:13
  So
• 9:13
  you
• 9:13
  can
• 9:13
  actually
• 9:13
  make
• 9:14
  the
• 9:14
  clonus
• 9:14
  happen.
• 9:15
  You
• 9:15
  can
• 9:15
  induce
• 9:15
  it
• 9:16
  by
• 9:16
  on
• 9:16
  a
• 9:17
  physical
• 9:17
  exam
• 9:18
  with
• 9:18
  agitation
• 9:19
  or
• 9:19
  diaphoresis.
• 9:20
  There's
• 9:20
  ocular
• 9:21
  clonus
• 9:21
  with
• 9:21
  agitation
• 9:22
  or
• 9:22
  diaphoresis,
• 9:23
  tremor
• 9:24
  and
• 9:24
  hyperreflexia
• 9:25
  or
• 9:26
  hypertonia.
• 9:27
  Temperature
• 9:27
  greater
• 9:28
  than
• 9:28
  38
• 9:29
  Celsius
• 9:29
  and
• 9:30
  ocular
• 9:30
  or
• 9:30
  inducible
• 9:31
  clonus.
• 9:31
  Again,
• 9:32
  Hunter
• 9:32
  serotonin
• 9:33
  toxicity
• 9:33
  criteria
• 9:34
  is
• 9:36
  similar
• 9:36
  to
• 9:37
  what
• 9:37
  I
• 9:37
  just
• 9:37
  shared
• 9:37
  with
• 9:37
  that
• 9:38
  algorithm,
• 9:38
  where
• 9:39
  there's
• 9:39
  a
• 9:39
  serotonergic
• 9:40
  agent
• 9:41
  and
• 9:41
  then
• 9:41
  you
• 9:41
  have
• 9:41
  one
• 9:42
  of
• 9:42
  those
• 9:42
  following
• 9:43
  problems.
• 9:43
  The
• 9:43
  clonus.
• 9:44
  Right.
• 9:44
  The
• 9:45
  clonus
• 9:45
  with
• 9:45
  agitation
• 9:46
  or
• 9:46
  sweating.
• 9:47
  The
• 9:47
  ocular
• 9:47
  clonus
• 9:48
  with
• 9:48
  agitation
• 9:49
  or
• 9:49
  sweating.
• 9:49
  It,
• 9:50
  Tremors
• 9:50
  and
• 9:50
  hyperreflexia.
• 9:52
  So
• 9:52
  a
• 9:53
  cluster
• 9:53
  of
• 9:53
  these
• 9:53
  symptoms.
• 9:54
  No
• 9:54
  need
• 9:54
  to
• 9:54
  really
• 9:54
  memorize
• 9:55
  that.
• 9:55
  But
• 9:55
  know
• 9:55
  that
• 9:56
  there
• 9:56
  is
• 9:56
  a
• 9:56
  Hunter
• 9:56
  criteria,
• 9:57
  the
• 9:58
  Hunter
• 9:58
  serotonin
• 9:59
  toxicity
• 9:59
  criteria,
• 10:00
  to
• 10:00
  help
• 10:00
  you
• 10:01
  navigate
• 10:01
  this.
• 10:01
  So
• 10:02
  you're
• 10:02
  not
• 10:02
  just
• 10:03
  guessing
• 10:04
  there's
• 10:04
  actual
• 10:05
  treatment
• 10:06
  that's
• 10:06
  tethered
• 10:07
  to
• 10:07
  this
• 10:07
  actual
• 10:07
  diagnostic
• 10:08
  criteria.
• 10:09
  Okay,
• 10:10
  now,
• 10:10
  differentials
• 10:11
  for
• 10:11
  this,
• 10:11
  Dale.
• 10:12
  Here
• 10:12
  in
• 10:12
  our
• 10:13
  er,
• 10:13
  of
• 10:13
  course,
• 10:14
  you
• 10:14
  can
• 10:14
  think
• 10:14
  of
• 10:14
  neuroleptic
• 10:15
  malignant
• 10:15
  syndrome,
• 10:16
  NMF
• 10:17
  anticholinergic
• 10:18
  toxicity
• 10:18
  and
• 10:18
  sepsis.
• 10:19
  But
• 10:19
  remember,
• 10:20
  NMS
• 10:21
  typically
• 10:21
  develops
• 10:21
  over
• 10:22
  days
• 10:22
  to
• 10:22
  weeks
• 10:22
  versus
• 10:23
  hours
• 10:23
  for
• 10:24
  serotonin
• 10:24
  syndrome,
• 10:25
  and
• 10:25
  it's
• 10:25
  usually
• 10:25
  more
• 10:26
  like
• 10:26
  lead
• 10:26
  pipe
• 10:27
  rigidity
• 10:27
  rather
• 10:27
  than
• 10:28
  hyperreflexia
• 10:29
  or
• 10:29
  clonus.
• 10:29
  Again,
• 10:30
  clonus
• 10:30
  has
• 10:31
  a
• 10:31
  very
• 10:31
  specific
• 10:31
  signature.
• 10:32
  Go
• 10:32
  on
• 10:32
  YouTube
• 10:33
  and
• 10:33
  find
• 10:33
  what
• 10:33
  clonus
• 10:34
  looks
• 10:34
  like,
• 10:34
  and
• 10:35
  you'll
• 10:35
  see
• 10:35
  that
• 10:35
  that's
• 10:35
  very
• 10:35
  different
• 10:36
  than
• 10:36
  this
• 10:36
  lead
• 10:36
  pipe
• 10:37
  rigidity,
• 10:37
  where
• 10:38
  the
• 10:38
  extremities
• 10:38
  don't
• 10:39
  move
• 10:39
  easily.
• 10:40
  In
• 10:40
  anticholinergic
• 10:41
  Toxicity,
• 10:42
  you
• 10:42
  would
• 10:42
  see
• 10:42
  dry
• 10:43
  skin.
• 10:43
  Not
• 10:43
  the
• 10:44
  diaphoresis
• 10:44
  we
• 10:44
  see
• 10:45
  in
• 10:45
  serotonin
• 10:45
  syndrome.
• 10:46
  You'd
• 10:46
  see
• 10:46
  urinary
• 10:47
  retention,
• 10:47
  decreased
• 10:48
  bowel
• 10:48
  sounds.
• 10:49
  Um,
• 10:49
  sepsis
• 10:50
  could
• 10:50
  be
• 10:50
  ruled
• 10:51
  out.
• 10:51
  If
• 10:51
  you
• 10:51
  get
• 10:51
  cultures
• 10:52
  and
• 10:52
  imaging,
• 10:52
  just
• 10:53
  know
• 10:53
  that
• 10:53
  these
• 10:53
  are
• 10:53
  the
• 10:53
  common
• 10:54
  differentials
• 10:54
  that
• 10:55
  clinicians
• 10:55
  might
• 10:55
  think
• 10:56
  about.
• 10:56
  But
• 10:56
  again,
• 10:57
  get
• 10:57
  to
• 10:57
  the
• 10:57
  root
• 10:57
  of
• 10:57
  this
• 10:58
  and
• 10:58
  you'll
• 10:58
  see
• 10:58
  serotonin
• 10:59
  is
• 10:59
  at
• 10:59
  the
• 10:59
  root
• 10:59
  of
• 10:59
  this,
• 11:00
  not
• 11:00
  an
• 11:00
  antipsychotic.
• 11:01
  So
• 11:01
  that's
• 11:02
  going
• 11:02
  to
• 11:02
  help
• 11:02
  you
• 11:02
  differentiate
• 11:03
  the
• 11:03
  two.
• 11:03
  Remember,
• 11:04
  the
• 11:04
  sweating
• 11:04
  is
• 11:04
  a
• 11:04
  good
• 11:04
  way
• 11:05
  to
• 11:05
  look
• 11:05
  at
• 11:05
  it,
• 11:05
  as
• 11:06
  opposed
• 11:06
  to
• 11:07
  feeling
• 11:07
  kind
• 11:07
  of
• 11:07
  dry,
• 11:08
  which
• 11:09
  would
• 11:09
  be
• 11:09
  more
• 11:09
  of
• 11:09
  an
• 11:09
  anticholinergic
• 11:10
  toxicity.
• 11:11
  The
• 11:11
  management
• 11:12
  of
• 11:12
  this
• 11:12
  typically
• 11:13
  is
• 11:13
  immediate
• 11:14
  discontinuation
• 11:14
  of
• 11:15
  all
• 11:15
  serotonergic
• 11:16
  agents.
• 11:16
  That's
• 11:16
  the
• 11:16
  cornerstone
• 11:17
  of
• 11:17
  treatment.
• 11:18
  Sometimes
• 11:18
  you
• 11:18
  can
• 11:19
  get
• 11:19
  back
• 11:19
  on
• 11:19
  your
• 11:19
  SSRI
• 11:20
  after
• 11:21
  the
• 11:21
  five
• 11:21
  half
• 11:21
  lives,
• 11:22
  wash
• 11:22
  it
• 11:22
  out
• 11:22
  completely,
• 11:23
  the
• 11:23
  offending
• 11:24
  agents
• 11:24
  are
• 11:24
  removed.
• 11:25
  I'll
• 11:25
  have
• 11:25
  you
• 11:26
  defer
• 11:26
  to
• 11:26
  individual
• 11:27
  cases
• 11:27
  and
• 11:28
  the
• 11:28
  evidence
• 11:28
  for
• 11:28
  that.
• 11:29
  But
• 11:29
  this
• 11:29
  is
• 11:29
  just
• 11:29
  giving
• 11:30
  you
• 11:30
  a
• 11:30
  conceptual
• 11:30
  appreciation.
• 11:31
  Immediate
• 11:32
  discontinuation
• 11:33
  of
• 11:33
  all
• 11:33
  serotonergic
• 11:34
  agents
• 11:34
  is
• 11:35
  usually
• 11:35
  the
• 11:35
  cornerstone
• 11:36
  of
• 11:36
  treatment.
• 11:36
  Treatment
• 11:37
  can
• 11:37
  vary
• 11:38
  based
• 11:38
  on
• 11:38
  the
• 11:38
  severity.
• 11:39
  In
• 11:39
  mild
• 11:40
  cases,
• 11:40
  you
• 11:40
  discontinue
• 11:41
  the
• 11:41
  offending
• 11:41
  agents.
• 11:42
  You
• 11:42
  might
• 11:42
  do
• 11:42
  supportive
• 11:43
  care
• 11:43
  with
• 11:43
  IV
• 11:44
  fluids,
• 11:44
  and
• 11:44
  you
• 11:45
  might
• 11:45
  give
• 11:45
  benzodiazepines
• 11:46
  for
• 11:46
  agitation.
• 11:47
  Remember,
• 11:47
  it's
• 11:48
  not
• 11:48
  just
• 11:48
  diaphoresis.
• 11:50
  It's
• 11:50
  not
• 11:50
  just
• 11:50
  hyperreflexia
• 11:52
  or
• 11:52
  clonus.
• 11:53
  We're
• 11:53
  also
• 11:54
  talking
• 11:54
  about
• 11:55
  agitation
• 11:56
  and
• 11:56
  confusion.
• 11:57
  Or
• 11:57
  don't
• 11:57
  underestimate
• 11:58
  the
• 11:58
  mental
• 11:59
  status
• 11:59
  component
• 12:00
  of
• 12:00
  this,
• 12:00
  the
• 12:00
  agitation,
• 12:01
  confusion,
• 12:01
  almost
• 12:02
  delirium.
• 12:02
  Benzodiazepines
• 12:04
  can
• 12:04
  help
• 12:04
  with
• 12:04
  that
• 12:04
  agitation
• 12:05
  piece,
• 12:05
  whether
• 12:05
  it
• 12:05
  be
• 12:06
  Valium
• 12:06
  or
• 12:06
  Ativan.
• 12:07
  For
• 12:07
  moderate
• 12:08
  cases,
• 12:08
  we
• 12:09
  do
• 12:09
  all
• 12:09
  of
• 12:09
  the
• 12:09
  above.
• 12:09
  But
• 12:10
  we
• 12:10
  might
• 12:10
  also
• 12:10
  consider
• 12:10
  ciproheptadine,
• 12:12
  12
• 12:12
  to
• 12:13
  32
• 12:13
  milligrams
• 12:13
  over
• 12:14
  24
• 12:14
  hours.
• 12:14
  Right.
• 12:15
  It's
• 12:15
  a
• 12:15
  5HT2A
• 12:16
  antagonist.
• 12:16
  For
• 12:17
  severe
• 12:17
  cases,
• 12:18
  we
• 12:19
  could
• 12:19
  be
• 12:19
  looking
• 12:19
  at
• 12:20
  ICU
• 12:20
  admission,
• 12:21
  aggressive
• 12:21
  cooling
• 12:22
  measures,
• 12:23
  orotracheal
• 12:23
  intubation,
• 12:24
  immediate
• 12:25
  sedation,
• 12:25
  and
• 12:26
  neuromuscular
• 12:26
  paralysis.
• 12:27
  This
• 12:27
  could
• 12:27
  get
• 12:27
  pretty
• 12:28
  bad,
• 12:28
  could
• 12:29
  be
• 12:29
  potentially
• 12:29
  fatal.
• 12:30
  And
• 12:30
  so
• 12:30
  we've
• 12:31
  gotta
• 12:31
  get
• 12:32
  ahead
• 12:32
  of
• 12:32
  this
• 12:32
  and
• 12:32
  treat
• 12:33
  it.
• 12:33
  And
• 12:33
  it
• 12:33
  is
• 12:33
  quite
• 12:34
  treatable
• 12:34
  once
• 12:34
  you
• 12:34
  identify
• 12:35
  it.
• 12:35
  But
• 12:36
  benzodiazepines
• 12:37
  are
• 12:37
  essential
• 12:37
  to
• 12:37
  control
• 12:38
  those
• 12:38
  levels
• 12:39
  of
• 12:39
  agitation
• 12:39
  and
• 12:40
  reduce
• 12:40
  the
• 12:40
  hyper
• 12:41
  adrenergic
• 12:42
  component.
• 12:42
  Right.
• 12:42
  Our
• 12:42
  vital
• 12:43
  signs
• 12:43
  are
• 12:43
  just
• 12:43
  on
• 12:44
  fire.
• 12:44
  Right.
• 12:44
  We
• 12:45
  have
• 12:45
  elevated
• 12:46
  heart
• 12:46
  rate,
• 12:47
  elevated
• 12:47
  temperature.
• 12:48
  We've
• 12:49
  got
• 12:49
  to
• 12:49
  really
• 12:49
  prioritize
• 12:50
  the
• 12:50
  benzodiazepines.
• 12:51
  In
• 12:51
  some
• 12:51
  of
• 12:51
  these
• 12:51
  cases,
• 12:52
  we
• 12:53
  want
• 12:53
  to
• 12:53
  discontinue
• 12:53
  the
• 12:54
  serotonergic
• 12:54
  medications.
• 12:55
  In
• 12:55
  this
• 12:55
  case,
• 12:55
  dale
• 12:56
  received
• 12:56
  Ativan,
• 12:57
  2mg
• 12:57
  IV
• 12:58
  for
• 12:58
  agitation.
• 12:59
  He
• 12:59
  got
• 12:59
  aggressive
• 13:00
  IV
• 13:00
  hydration,
• 13:01
  external
• 13:01
  cooling
• 13:02
  measures.
• 13:03
  He
• 13:03
  was
• 13:03
  given
• 13:03
  12mg
• 13:04
  through
• 13:05
  an
• 13:05
  NG
• 13:05
  tube.
• 13:06
  Within
• 13:06
  six
• 13:07
  hours,
• 13:07
  his
• 13:07
  temperature
• 13:08
  normalized.
• 13:08
  His
• 13:09
  mental
• 13:09
  status
• 13:09
  began
• 13:10
  improving.
• 13:10
  By
• 13:11
  24
• 13:11
  hours,
• 13:11
  his
• 13:12
  Clonus
• 13:12
  and
• 13:12
  hyperreflexia
• 13:13
  had
• 13:13
  resolved.
• 13:14
  He
• 13:14
  was
• 13:15
  discharged
• 13:16
  with
• 13:16
  follow
• 13:16
  up
• 13:17
  and
• 13:17
  educated
• 13:17
  about
• 13:17
  how
• 13:18
  to
• 13:18
  avoid
• 13:18
  serotonergic
• 13:19
  drug
• 13:20
  combinations
• 13:20
  in
• 13:21
  the
• 13:21
  future.
• 13:22
  I
• 13:22
  hope
• 13:22
  you
• 13:22
  got
• 13:23
  a
• 13:23
  decent
• 13:23
  amount
• 13:23
  of
• 13:24
  pearls
• 13:24
  out
• 13:24
  of
• 13:24
  this.
• 13:25
  I
• 13:25
  really
• 13:26
  want
• 13:26
  to
• 13:26
  emphasize
• 13:26
  clonus
• 13:27
  and
• 13:27
  what
• 13:27
  that
• 13:28
  looks
• 13:28
  like,
• 13:28
  how
• 13:29
  you
• 13:29
  can
• 13:29
  induce
• 13:29
  clonus
• 13:30
  by
• 13:30
  rapidly
• 13:31
  dorsiflexing
• 13:32
  the
• 13:32
  foot,
• 13:32
  but
• 13:32
  that
• 13:33
  there's
• 13:33
  also
• 13:33
  other
• 13:33
  spontaneous
• 13:35
  or
• 13:35
  ocular
• 13:35
  clonus
• 13:36
  that
• 13:36
  I
• 13:36
  want
• 13:36
  you
• 13:37
  to
• 13:37
  look
• 13:37
  at.
• 13:37
  Another
• 13:37
  key
• 13:38
  pearl
• 13:38
  today
• 13:38
  to
• 13:38
  summarize
• 13:39
  is
• 13:39
  that
• 13:39
  serotonin
• 13:40
  syndrome
• 13:40
  typically
• 13:41
  develops
• 13:41
  within
• 13:41
  hours
• 13:42
  of
• 13:42
  drug
• 13:43
  initiation
• 13:43
  or
• 13:43
  dose
• 13:44
  increase
• 13:44
  or
• 13:45
  adding
• 13:45
  the
• 13:45
  second
• 13:45
  serotonergic
• 13:46
  agent,
• 13:47
  not
• 13:47
  days
• 13:47
  or
• 13:47
  weeks
• 13:47
  like
• 13:48
  NMS.
• 13:48
  Most
• 13:49
  cases
• 13:49
  occur
• 13:49
  within
• 13:50
  6
• 13:50
  to
• 13:50
  24
• 13:50
  hours
• 13:51
  of
• 13:51
  the
• 13:51
  precipitating
• 13:52
  event.
• 13:52
  Remember,
• 13:52
  this
• 13:53
  can
• 13:53
  even
• 13:53
  happen
• 13:53
  at
• 13:54
  therapeutic
• 13:54
  doses.
• 13:55
  This
• 13:55
  is
• 13:55
  not
• 13:55
  just
• 13:56
  overdoses,
• 13:56
  although
• 13:57
  that's
• 13:57
  probably
• 13:57
  most
• 13:58
  cases
• 13:58
  or
• 13:59
  drug
• 13:59
  combinations,
• 14:00
  which
• 14:00
  may
• 14:00
  be
• 14:00
  most
• 14:01
  cases.
• 14:01
  But
• 14:01
  this
• 14:01
  could
• 14:01
  also
• 14:02
  happen
• 14:02
  at
• 14:02
  normal
• 14:03
  therapeutic
• 14:04
  doses.
• 14:04
  And
• 14:04
  that's
• 14:04
  important
• 14:05
  because
• 14:05
  you
• 14:06
  shouldn't
• 14:06
  have
• 14:06
  your
• 14:06
  guard
• 14:07
  down
• 14:07
  just
• 14:07
  because
• 14:07
  your
• 14:07
  patient
• 14:08
  is
• 14:08
  trying
• 14:08
  20
• 14:09
  or
• 14:09
  30
• 14:09
  milligrams
• 14:09
  of
• 14:10
  Prozac.
• 14:10
  Remember
• 14:11
  that
• 14:11
  genetic
• 14:12
  variations
• 14:12
  in
• 14:12
  drug
• 14:13
  metabolism
• 14:14
  can
• 14:14
  certainly
• 14:14
  result
• 14:15
  in
• 14:16
  radical
• 14:17
  changes
• 14:17
  and
• 14:18
  ways
• 14:18
  that
• 14:18
  we
• 14:18
  respond
• 14:19
  to
• 14:19
  these
• 14:19
  serotonergic
• 14:20
  medications.
• 14:20
  So
• 14:21
  be
• 14:21
  on
• 14:21
  the
• 14:21
  lookout
• 14:21
  for
• 14:21
  that.
• 14:21
  Remember,
• 14:22
  combined
• 14:22
  with
• 14:22
  SSRIs
• 14:23
  or
• 14:23
  SNRIs
• 14:24
  pose
• 14:24
  the
• 14:24
  highest
• 14:25
  risk
• 14:25
  and
• 14:26
  that's
• 14:26
  a
• 14:26
  big
• 14:26
  deal.
• 14:26
  We
• 14:27
  need
• 14:27
  a
• 14:27
  two
• 14:27
  week
• 14:28
  washout
• 14:28
  there.
• 14:29
  Five
• 14:29
  weeks
• 14:29
  if
• 14:29
  it's
• 14:30
  Prozac.
• 14:30
  When
• 14:30
  switching
• 14:31
  between
• 14:31
  these
• 14:32
  drug
• 14:32
  classes,
• 14:33
  remember
• 14:33
  about
• 14:34
  the
• 14:34
  benzos
• 14:34
  that
• 14:34
  we
• 14:34
  talked
• 14:35
  about,
• 14:35
  how
• 14:35
  it's
• 14:35
  typically
• 14:35
  first
• 14:36
  line
• 14:36
  treatment,
• 14:37
  regardless
• 14:37
  of
• 14:37
  severity,
• 14:38
  that
• 14:39
  really
• 14:39
  helps
• 14:39
  reduce
• 14:40
  the
• 14:40
  muscle
• 14:40
  activity,
• 14:41
  controls
• 14:41
  the
• 14:41
  agitation,
• 14:42
  it
• 14:43
  blunts
• 14:43
  that
• 14:43
  hyper
• 14:44
  adrenergic
• 14:44
  response.
• 14:45
  Early
• 14:46
  sedation
• 14:46
  really
• 14:46
  improves
• 14:47
  outcomes
• 14:48
  here.
• 14:48
  Remember
• 14:49
  that
• 14:49
  prognosis
• 14:49
  is
• 14:50
  very
• 14:50
  good.
• 14:50
  If
• 14:50
  we
• 14:50
  recognize
• 14:51
  this
• 14:51
  early
• 14:51
  and
• 14:52
  and
• 14:52
  manage
• 14:52
  it
• 14:52
  appropriately.
• 14:54
  Serotonin
• 14:54
  syndrome
• 14:55
  has
• 14:55
  a
• 14:55
  favorable
• 14:56
  prognosis.
• 14:57
  Most
• 14:57
  cases
• 14:57
  resolve
• 14:58
  within
• 14:58
  24
• 14:58
  hours.
• 14:59
  But
• 14:59
  we've
• 14:59
  gotta
• 14:59
  identify
• 15:00
  it
• 15:00
  and
• 15:00
  intervene
• 15:01
  accordingly.
• 15:02
  I
• 15:02
  really
• 15:02
  hope
• 15:03
  this
• 15:03
  gave
• 15:03
  you
• 15:03
  a
• 15:04
  lot
• 15:04
  of
• 15:04
  good
• 15:04
  information.
• 15:04
  I
• 15:05
  know
• 15:05
  it
• 15:05
  was
• 15:05
  very
• 15:05
  helpful
• 15:05
  for
• 15:06
  me
• 15:06
  to
• 15:06
  identify
• 15:07
  the
• 15:07
  clusters
• 15:07
  here
• 15:08
  and
• 15:08
  to
• 15:09
  know
• 15:09
  what
• 15:09
  to
• 15:09
  do.
• 15:10
  Um,
• 15:10
  and
• 15:10
  like
• 15:11
  I
• 15:11
  said,
• 15:11
  if
• 15:11
  you
• 15:11
  become
• 15:11
  Patreon
• 15:12
  members,
• 15:12
  we're
• 15:12
  gonna
• 15:13
  have
• 15:13
  a
• 15:13
  really
• 15:13
  good
• 15:14
  essential
• 15:15
  serotonin
• 15:15
  syndrome.
• 15:16
  Go
• 15:16
  by
• 15:16
  of
• 15:17
  everything
• 15:17
  you
• 15:17
  need
• 15:17
  to
• 15:17
  know
• 15:17
  so
• 15:18
  you
• 15:18
  can
• 15:18
  visually
• 15:18
  see
• 15:18
  this.
• 15:19
  We
• 15:19
  also
• 15:19
  have
• 15:20
  links
• 15:20
  that
• 15:21
  are
• 15:21
  key
• 15:21
  if
• 15:21
  you
• 15:21
  become
• 15:21
  a
• 15:22
  Patreon
• 15:22
  member,
• 15:22
  you
• 15:23
  can
• 15:23
  look
• 15:23
  at
• 15:23
  those
• 15:23
  in
• 15:23
  the
• 15:23
  show
• 15:24
  notes.
• 15:24
  We
• 15:24
  make
• 15:24
  things
• 15:24
  really
• 15:25
  simple
• 15:25
  for
• 15:25
  you
• 15:26
  to
• 15:26
  pass
• 15:26
  your
• 15:26
  boards
• 15:27
  and
• 15:27
  thrive
• 15:27
  in
• 15:27
  practice.
• 15:28
  Very
• 15:28
  good
• 15:29
  visual
• 15:30
  handouts
• 15:31
  and
• 15:31
  go
• 15:31
  buys
• 15:32
  that
• 15:32
  make
• 15:32
  life
• 15:33
  a
• 15:33
  lot
• 15:33
  easier.
• 15:33
  It
• 15:34
  was
• 15:34
  a
• 15:34
  real
• 15:34
  pleasure
• 15:34
  chatting
• 15:35
  with
• 15:35
  all
• 15:35
  of
• 15:35
  you
• 15:35
  today.
• 15:35
  Again,
• 15:36
  this
• 15:36
  is
• 15:36
  npz,
• 15:37
  your
• 15:37
  preceptor
• 15:38
  in
• 15:38
  your
• 15:38
  pocket.
• 15:38
  It
• 15:39
  really
• 15:39
  helps
• 15:39
  if
• 15:39
  you
• 15:39
  give
• 15:39
  us
• 15:39
  five
• 15:40
  stars
• 15:40
  on
• 15:40
  Apple
• 15:40
  and
• 15:41
  write
• 15:41
  a
• 15:41
  little
• 15:41
  comment.
• 15:41
  Spread
• 15:42
  the
• 15:42
  podcast
• 15:42
  out.
• 15:43
  It's
• 15:43
  really
• 15:43
  helped
• 15:44
  a
• 15:44
  lot
• 15:44
  of
• 15:44
  people.
• 15:44
  We're
• 15:44
  in
• 15:44
  many
• 15:45
  different
• 15:45
  countries
• 15:45
  now.
• 15:46
  We
• 15:46
  appreciate
• 15:47
  all
• 15:47
  the
• 15:47
  love.
• 15:47
  You
• 15:48
  can
• 15:48
  also
• 15:48
  email
• 15:48
  me
• 15:49
  in
• 15:49
  the
• 15:49
  show
• 15:50
  notes.
• 15:50
  I
• 15:50
  have
• 15:50
  an
• 15:50
  email
• 15:50
  address
• 15:51
  there
• 15:51
  that
• 15:52
  we
• 15:52
  can
• 15:52
  talk
• 15:53
  about
• 15:53
  future
• 15:53
  episode
• 15:54
  ideas
• 15:54
  that
• 15:55
  you
• 15:55
  may
• 15:55
  have,
• 15:56
  questions
• 15:56
  you
• 15:56
  may
• 15:56
  have.
• 15:57
  Really
• 15:57
  building
• 15:57
  a
• 15:58
  study
• 15:58
  hall,
• 15:58
  a
• 15:58
  great
• 15:58
  community
• 15:59
  together.
• 15:59
  Encourage
• 16:00
  you
• 16:00
  to
• 16:00
  look
• 16:00
  at
• 16:00
  all
• 16:00
  the
• 16:00
  other
• 16:00
  past
• 16:01
  episodes.
• 16:01
  There's
• 16:01
  some
• 16:02
  goodies
• 16:02
  there
• 16:02
  that
• 16:02
  really
• 16:02
  put
• 16:03
  this
• 16:03
  all
• 16:03
  together.
• 16:04
  All
• 16:04
  right
• 16:04
  y'
• 16:04
  all
• 16:04
  take
• 16:04
  care.
• 16:05
  Bye
• 16:05
  bye.