Pediatric Selective Serotonin Reuptake Inhibitor Toxicity Medication

Updated: Sep 27, 2019
  • Author: Mohamed K Badawy, MD, FAAP; Chief Editor: Stephen L Thornton, MD  more...
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Medication

Medication Summary

No drug of choice (DOC) for the treatment of serotonin syndrome has been identified; management is mainly supportive. Adequate hydration should be addressed before the initiation of any medication.

As previously mentioned, antihypertensives often are unnecessary unless the hypertension is persistent and clinically significant. If needed, the agent should have a short half-life. Seizures and muscular rigidity are managed best by the use of a benzodiazepine such as clonazepam or lorazepam.

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Decontaminants

Class Summary

These agents decrease the extent to which selective serotonin reuptake inhibitors (SSRIs) and other serotonergic substances are absorbed from the GI tract, thereby reducing systemic toxicity.

Activated charcoal (Actidose-Aqua, Liqui-Char, EZ-Char, Kerr Insta-Char)

Activated charcoal is used in the emergency treatment of poisoning caused by drugs and chemicals. A network of pores present in activated charcoal adsorbs 100-1000mg of drug per gram of charcoal. Activated charcoal does not dissolve in water. For maximum effect, administer it within 30 minutes of poison ingestion.

GI decontamination with activated charcoal should be performed with careful attention to the possibility of impending airway compromise. If progressive deterioration is present, secure the airway via endotracheal intubation before any decontamination attempts.

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Antihypertensives, Other

Class Summary

Antihypertensives, if needed, should have a short half-life because of the rapid changes in cardiovascular status in these patients. Sodium nitroprusside is the preferred agent because of its rapid onset and short half-life. It should be used only in a closely monitored setting. An arterial catheter should be inserted before its use.

Nitroglycerin has been used successfully to treat adults with serotonin syndrome. Limited data suggest that its use cannot be recommended in the pediatric population.

Sodium nitroprusside (Nitropress)

Sodium nitroprusside produces arterial and venous vasodilation. It decreases afterload and preload and may produce a reflex tachycardia.

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Antidotes, Other

Class Summary

Serotonin antagonists (eg, cyproheptadine, chlorpromazine) have been used successfully in isolated cases of serotonin syndrome. Most of the available information is derived from case reports. Further studies are needed before their general use can be recommended.

Cyproheptadine, an antihistamine with antiserotonergic properties, has been shown in animal studies and case reports to reduce the symptoms of serotonin syndrome. Chlorpromazine has been used effectively in some case reports, but neuroleptic malignant syndrome (NMS) must be ruled out before its use. Chlorpromazine may potentiate seizures by lowering the seizure threshold. Propranolol has mild serotonin antagonist properties.

Cyproheptadine (Periactin)

Cyproheptadine has been shown in animal studies and case reports to reduce the symptoms of serotonin syndrome. It may be helpful in mild-to-moderate cases of serotonin syndrome. Cyproheptadine is available in the form of tablets or oral suspension.

Chlorpromazine

Following charcoal administration, chlorpromazine is a better choice in treating toxicity because it can be administered IV while cyproheptadine is not available IV. However, it is best to avoid chlorpromazine if the drugs inducing serotonin toxicity have significant cardiogenic or epileptogenic properties.

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Sedatives and Anticonvulsants

Class Summary

Benzodiazepines are useful, particularly for the control of seizures and agitation. Clonazepam may be useful, especially in the setting of myoclonus.

Clonazepam (Klonopin)

Clonazepam is an anticonvulsant that may be useful in the setting of myoclonus.

Lorazepam (Ativan)

Lorazepam is a benzodiazepine used for the control of seizures and agitation.

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