Intentional Overdose
Triage Note
“Overdose”
Initial Vitals
T 36.5 C HR 91 BP 105/57 RR 20 O2 sat 94% on RA.
Presentation
A 31-year-old female with history of hyperemesis, suicidal ideation presents to the emergency department after an intentional overdose. Approximately 1 hour prior to arrival, in an apparent suicide attempt, the patient locked herself in a bathroom and took approximately 60 tablets of a "psychiatric medication" and 45 tablets of 500 mg Nyquil, which includes 325 mg of acetaminophen, 15 mg of dextromethorphan, and 6.25 mg of doxylamine succinate per tablet. In route to emergency department patient became increasingly altered, upon arrival to ED was GCS 14 with confused speech. Upon arrival patient immediately had a tonic-clonic seizure episode, which did not stop with lorazepam or levetiracetam. The patient was intubated for status epilepticus after receiving phenobarbital. While further information regarding the patient's history was limited, the following physical exam finding was noted:
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GENERAL: Intubated for airway protection, sedated.
HEAD: Head is normocephalic.
Pupils: PERRL
ENT: Moist mucous membranes.
CHEST: Mechanically ventilated Clear to auscultation bilaterally. No wheezing, rales, or rhonchi
CV: Regular rate and rhythm. No murmurs, rubs, or gallops
ABDOMEN: Soft, non-distended
EXTREMITIES: Normal to inspection and palpation. No deformity
SKIN: Warm and dry. No diaphoresis. No obvious rashes.
NEUROLOGIC: Patient is intubated. Facial symmetry. Additional finding as below:
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Laboratory workup was negative for leukocytosis, anemia, thrombocytopenia. No major electrolyte abnormalities, renal function, or liver dysfunction was present. Acetaminophen level pending.
Exam Finding
ED Course Outcome/Discussion
The above finding is clonus, which is consistent with a diagnosis of serotonin syndrome.
Serotonin syndrome presents as a “triad of autonomic instability, altered mental status, and neuromuscular findings (eg, hyperreflexia, clonus) in the context of exposure to a serotonergic agent.” This condition can be caused by any serotonergic agent, such as SSRI/SNRI medications, but is seen more commonly as a side effect of monoamine oxidase inhibitors (MAOIs).
The patient’s family revealed that the patient had intentionally ingested a bottle of fluoxetine. She remained intubated for status epilepticus and did emperically receive N-acetyl cystine for her acetaminophen ingestion, although it was later determined that she was under the toxic threshold. The patient was transferred to a facility with continuous EEG capabilities and was later extubated. After medical clearance, the patient was transferred to an inpatient psychiatric facility for further care.
Brown K. Antidepressant Toxicity and Poisoning. In: Johnson W, Nordt S, Mattu A and Swadron S, eds. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/reculrwaECMipmENh/Antidepressant-Toxicity-and-Poisoning#h.jl5m6vv2alr5. Updated August 4, 2021. Accessed April 3, 2024.
Takeaway Points
The defining physical exam finding of serotonin syndrome is clonus
Serotonin syndrome is primarily treated with aggressive supportive care, with benzodiazepines and cyproheptadine in severe cases
Perform a thorough review of all home medications in intentional overdose cases
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