Delirium
The two main types of delirium.
What are hypo- and hyper- active?
There is also a mixed.
Hypoactive carries a poorer prognosis.
SSRI with the longest and SSRI with the shortest half life.
What are fluoxetine and fluvoxamine?
Fluoxetine has a long elimination half-life, ranging from 1 to 3 days after a single dose and 4 to 6 days with chronic use. Its active metabolite, norfluoxetine, persists even longer, with a half-life of 7 to 16 days, causing significant accumulation in the body and requiring several weeks to fully clear after stopping the medication.
Paroxtine is a close second-shortest.
Fluvoxamine generally has an elimination half-life of 13–26 hours (often ~15-20h), while paroxetine typically has a half-life of 15–24 hours, though some data suggests around 21 hours.
True or false: Tylenol is effective for SS related fever.
What is false? The origin is peripheral.
These SSRIs are most likely to interfere with the metabolism of other drugs (e.g., Codeine or Warfarin) due to their inhibition of CYP2D6.
What are paroxetine and fluoxetine?
'Teens' like to interact.
True or false: Serotonin syndrome presents more in the lower extremities than upper.
What is true?
True or false: Turn off the lights during the day so the delirious patient is not overstimulated and can rest.
What is false?
https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2024.1403842/full
Patients did better with bright lights, cognitive stimulation.
SSRI considered safest for a breastfeeding patient.
what is sertraline?
_ _ _ _ _ _ _ _ _ _ _ _ _ and _ _ _ _ _ _ _ _ _ are the most common findings.
What is hyperreflexia and myoclonus being the most common findings?
This SSRI is most notorious for causing gastrointestinal (GI) upset, such as diarrhea, often nicknamed "_______ squirts"
What is sertraline?
Serotonin usually presents _ to _ _ hours after a change in serotonergic meds.
Just knowing the general timeline is important.
What is 6 to 24 hours?
NMS often develops subacutely, within days to weeks.
True or false: One should always avoid benzos use in delirious patients.
What is false?
Forgetting about substance WD delirium, lorazepam can be used as an adjunct to haloperidol in severe agitation with some studies showing improvments without affecting length of stay or mortality. Still, maximize other agents first.
True or false: SSRIs are generally considered to be free of movement disorder side effects like akathisia.
What is false?
SSRIs are associated with akathisia. Other EPS appear rarer. Oddly, escitalopram appears to be lower risk for akathisia; there are cases though. I do not know why. Bruxism and RLS are other motor SE.
True or false: Serotonin syndrome is associated with an increased risk of DVT/PE.
What is true?
This SSRI is most associated with anticholinergic side effects (e.g., dry mouth, constipation) and sedation.
What is paroxetine?
The _ _ _ _ _ _ Criteria are the most accurate for making a diagnosis.
What are the Hunter Criteria?
Haloperidol is still a drug of choice for agitation. It has been seen that, even in ill/elderly/ patients with limited cardiac risk, doses of < this no not require cardiac monitoring.
What is 5mg? Even for IV.
The point here is that you don't need to get the serial EKGs the medicine teams often get.
This SSRI is considered "activating" and might be a good choice for a patient with low energy (hypersomnia) but could be poor choice for someone with high anxiety, causing jitteriness.
What is fluoxetine?
Sertraline is #2 here.
All of the supporting signs/sx in the Hunter criteria require "movement": spontaneous or inducible or ocular myoclonus as a precursor to make the diagnosis of serotonin syndrome, except these two symptoms occurring together on their own.
What are tremor and hyperreflexia?
SSRI FDA approved for bulimia nervosa.
What is fluoxetine?
True or false: Dantrolene is effective for rigidity and fever in serotonin syndrome.
What is false?
Dantrolene is largely ineffective in serotonin syndrome because it directly acts on skeletal muscle calcium release, whereas serotonin syndrome is a central nervous system pathology driven by excess 5-HT, not primary peripheral muscle failure. It cannot reverse the central serotonergic toxicity.
Serotonin (5-HT) acts as a complex modulator of body temperature within the central nervous system, primarily acting through the hypothalamus to either induce hyperthermia or hypothermia depending on the receptor subtype. It facilitates cold-defense mechanisms (shivering, thermogenesis) via 5-HT2 receptors and increases heat loss (vasodilation) or reduces heat production via 5-HT1A/5-HT3/5-HT7 receptors.
Considered a treatment of last resort for protracted delirium, especially with agitation that is difficult to control.
What is ECT?
This is a case. There are some review papers.
I would m/l try Prededex first:
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14472
Initial loading dose of 1 mcg/kg over 10 minutes followed by an infusion of 0.2–0.7 mcg/kg/hour
If a patient has significant liver or kidney disease, these two SSRIs are preferred because their plasma levels rise in direct proportion to the dose (linear kinetics).
What are sertraline and citalopram?
Unlike fluoxetine or paroxetine, which can reach disproportionately high levels at higher doses, these two are easier to predict and manage in patients with impaired organ function.
This histamine-1 receptor antagonist with nonspecific 5-HT1A and 5-HT2A antagonistic properties is used when initial management with benzos is ineffective (Even though evidence is weak overall).
What is cyproheptadine?
This SSRI is sedating, short acting, features a relatively elevated risk for interactions, and has a primary approval for and is generally used only in OCD.
What is fluvoxamine?
True or false: If you have an NMS v SS ddx, administer bromocriptine.
What is false?
It is an agonist at 2 subtypes of 5HT1a receptors and 5HT2a as well.