THE ACUTELY ALTERED

TEEN

Morning Report 6/24/15

Erin Helms
Family Medicine R2

HPI
13 year old female
Brought to ED by her father
Sudden onset of falling, confusion,
eventually vomiting
Acting normally when she got home from
school

MEDICAL AND SOCIAL

HISTORY
Depression
Started counseling last month
Prozac 20 mg qday
Trazodone 50 mg qhs prn insomnia
Self-injury
2 months of cutting
Last time 2 days ago
Strong family history of mental illness and suicide
Lives with grandparents who have custody. Sees dad regularly.

EXAM 02:00 (AT

PRESENTATION)
T 37.2. HR 160. RR 25. BP 112/52. SaO2 93% on RA
GEN: Sleepy, wakes to voice. Slurred speech. Confused.
Tangential.
EYES: Pupils 3 mm, reactive. Prominent ocular clonus bilaterally,
EOMI.
HENT: WNL
CV/PULM: Tachycardic.
ABDOMEN: WNL
NEURO: Fine tremor with activity. Normal UE tone. Increased LE
tone. 6 beats of inducible ankle clonus bilaterally. 3+ patellar
DTRs. Ataxic.
SKIN: warm and flushed. Cuts across UEs.

DIFFERENTIAL DIAGNOSIS

DIFFERENTIAL DIAGNOSIS
Toxic
Ingestions: anticholinergic, sympathomimetic, salicylates, serotonin-syndrome
Withdrawal states: Barbiturates, ethanol (DTs), sedative-hypnotics

Endo: Thyroid storm

ID: Tetanus, meningitis, sepsis
Neuro: Stroke, tumor
Misc: Malignant hyperthermia, neuroleptic malignant syndrome

WORK UP
CBC: Normal
BMP: Normal
CK: Normal
VBG: 7.34/33/65/17.2
Serum tox: Negative EtOH, acetaminophen, salicylate
Urine tox: + PCP, + Opiate
Urine pregnancy: Negative
EKG: Sinus tachycardia. Normal QTc.

ADDITIONAL HPI
Grandpa calls with more information
Recent suicidal threats
Admits to an ingestion of a handful of pills
from local grocery store
Prescription pills counted, all accounted for

ADDITIONAL HPI
Called Poison Control back with additional information

Consulted toxicology
Learned that DEXTROMETHORPHAN:
Causes false positive drug screens
Is a dissociative general anesthetic & hallucinogen
at high doses
Is what kids these days are doing for fun
When mixed with serotonergic meds, can cause

SEROTONIN
SYNDROME

FEATURES OF SEROTONIN
SYNDROME

Cognitive/Behavioral
Confusion/disorientation
Agitation/irritability
Coma
Anxiety
Hypomania/seizures/
hallucinations
Autonomic
Hyperthermia
Diaphoresis
Sinus tachycardia
Hypertension
Tachypnea/mydriasis

54%
35%
28%
16%
15%

46%
46%
41%
33%
27%

Neuromuscular
Myoclonus
Hyperreflexia
Muscle
rigidity/tremor
Hyperactivity/
restlessness
Ataxia

57%
50%
49%
42%
38%

HUNTER SEROTONIN TOXICITY

CRITERIA
In patients with known ingestion of a serotonergic agent (one of the
following):
Spontaneous clonus
Inducible clonus + agitation or diaphoresis
Ocular clonus + agitation or diaphoresis
Tremor + hyperreflexia
Hypertonia + temperature > 100.4F + ocular or inducible clonus
Sensitivity 84% and Specificity 97%

MEDICATIONS

THAT MAY CONTRIBUTE TO SEROTONIN

SYNDROME
Amphetamines

Antidepressants

Antiemetics

Ecstasy

Buspirone

Metoclopramide

Dextroamphetamine

Lithium

Ondansetron

Methamphetamine

MOAIs

Antimigraine Drugs

Sibutrimine

SSRIs

Carbamazepine

SNRIs

Ergot alkaloids

Cyclobenzaprine

Trazodone

Triptans

Fentanyl

TCAs

Valproic acid

Analgesics

Meperidine

Miscellaneous

Tramadol

Cocaine
Dextromethorphan
Linezolid
St. Johns Wort

TREATMENT
Stop all serotonergic medications
Symptom control
Hyperthermia: external cooling measures
Agitation, myoclonus: benzodiazepines (Lorazepam 0.02 to 0.04 mg/kg/dose in
children)

Cyproheptadine (serotonin antagonist)

Monitor for rhabdomyolysis, DIC, metabolic acidosis
Mortality rate 11-15%

EXAM 14:00 (AFTER ATIVAN)

T 37.0. HR 95 RR 16. BP 123/81.
GEN: Lying in bed quietly
EYES: Pupils 3mm, reactive. Inducible ocular clonus with upward
gaze and lateral gaze
HENT: WNL
CV/PULM: WNL
ABD: WNL
NEURO: Normal UE tone. Increased LE tone. 3-4 beats of inducible
ankle clonus bilaterally. 3+ patellar DTRs.
SKIN: Pale.

EXAM 08:00 (AFTER

CYPROHEPTADINE)

T 37.4. HR 102. BP 118/61. RR 20.

Gen: Awake, Alert, NAD

Eyes: Pupils 3 mm, reactive. Ocular clonus present but decreased

from yesterday.
HENT: WNL
CV/PULM: WNL
ABD: WNL

NEURO: Normal UE tone. Mildly increased LE tone. No ankle

clonus. 2+ patellar DTRs.
Skin: WNL

FALSE POSITIVE DRUG

SCREEN

Opiates

Phencyclidine

Dextromethorphan

Dextromethorphan

Diphenhydramine

Diphenhydramine

Fluoroquinolones

Dextroamphetamine

Poppy seeds and oil

Doxylamine

Rifampin

Ibuprofen

Quinine

Imipramine
Ketamine
Meperidine
Thioridazine
Tramadol
Venlafaxine

REFERENCES
Ables, A et al. Prevention, Diagnosis, and Management of Serotonin
Syndrome. American Family Physician. 2010; 81 (9) 1139-1142.
Arnold, D. Consultation With the Specialist: The Central Serotonin
Syndrome: Paradigm for Psychotherapeutic Misadventure. PEDIATRICS
IN REVIEWDecember 1, 2002vol. 23no. 12427432doi:10.1542/pir.23-12-427
UpToDate: Serotonin Syndrome
Woelfel JA. Drug abuse urine tests: false-positive results.Pharmacist's
Letter/Prescriber's Letter2005;21(3):210314.