You are called to a 26-year-old male who has taken an overdose of their anti-depressant medication. The mother has called concerned as they have taken overdoses before after periods of low mental health. The call is graded lower priority so unfortunately you arrive 6 hours after the initial call. On arrival you find the patient alert and orientated but seems restless and agitated. The patient is quite withdrawn and not wanting to speak to anyone, so you start an assessment and try to build rapport with help of the mother.
Initial observations include 105HR, 18 RR, 98% Sp02, 127/75 BP, 37.8 Temp, 5.4 BM.
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What is an aide memoire for the assessment of risk to self of suicidal patients?
The patient starts to open up as you continue conversation. You apply the IIPAP tool and deem the patient currently at low risk of further harm. They have calmed significantly since the event and regret the decision they made at the time. They explain they have been feeling low recently and took the overdose after an argument with several friends. They have taken 50 x 50mg Sertraline, 5 x 2mg Diazepam, and 10 x 10mg fluoxetine.
What kind of medication is Sertraline?
What kind of medication is Fluoxetine?
You are now almost 7 hours post ingestion. The patient is calm, but something doesn’t seem right. You notice the patient is diaphoretic and has an intermittent, small tremor in his legs. Their observations are still normal with exception of their tachycardia at 112 and temperature of 37.9. What diagnosis would more concern you after the patient has taken these medications?
What is the bioavailability of oral diazepam and its’ relative peak plasma concentrations times which may help in your assessment of this overdose?
During further history you discover that the patient has been taking a further supplement called tryptophan that seems to help their depression. Should this increase our clinical concern?
You are concerned about the likelihood of Serotonin syndrome as the patient’s symptoms progress. The tremors are more continuous now and have been continually ongoing for 5 minutes, similar to a focal seizure. The patient is still alert.
Can you give Diazepam to cease this at this point?
What other treatment/management plans can be beneficial for the management of this patient?
Why should these patients be transported to hospital quickly with a pre-alert provided if they are displaying deteriorating symptoms?
Hyperthermia associated with serotonin syndrome is not very well treated with traditional antipyretics as it is caused by increased muscle tone rather than impeded central thermoregulation?
What other symptoms are associated with serotonin syndrome?
Mild cases of serotonin syndrome are usually overlooked or put down to anxiety or other mental health conditions?
What test can be used to help diagnose Serotonin syndrome?
Serotonin syndrome can present in patients who have had recent changes in antidepressant medication and result in accumulated toxicity over days?
Once a temperature of 38.5 is surpassed, it is recommended to closely monitor temperature every 30 minutes and start urgent cooling measures. What could these include?
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