Version May 2024
| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222, or the nearest international regional poison center. Contact information for regional poison centers around the world is available at the website referenced below.[1] |
| Overview |
| SSRIs rarely cause significant toxicity in isolated ingestions |
| Search for coingestants in any patient with significant symptoms |
| Serotonin syndrome, seizure, and QTc prolongation are rare but dangerous complications |
| Citalopram is the most toxic SSRI in overdose |
| History |
| Ascertain the drugs ingested (including coingestants and formulations) |
| Ascertain the amounts ingested and when the ingestion occurred |
| Physical examination |
| First, assess and secure airway, breathing, and circulation |
| Examination usually unremarkable; infrequently drowsiness, tremor, and vomiting can occur |
| Evaluate for serotonin syndrome: hyperthermia, diaphoresis, ocular clonus, hypertonia, tremor, lower extremity hyperreflexia, ankle clonus |
| Laboratory evaluation |
| Obtain the following: acetaminophen and salicylate serum concentrationss; serum ethanol concentration; electrocardiogram (ECG); serum bicarbonate; pregnancy test in women of childbearing age |
| Obtain serial ECGs if QRS or QTc interval is prolonged on initial ECG; admit patient if conduction abnormalities persist; citalopram and escitalopram are most likely to cause prolonged intervals |
| Obtain the following if severe serotonin syndrome is suspected: creatine kinase, urine myoglobin; serum creatinine; serum aminotransferases; coagulation studies (aPTT, PT, INR, platelet count, d-dimer); arterial blood gas |
| Treatment |
| Most SSRI ingestions cause minimal toxicity; supportive care is generally sufficient |
| Secure airway, breathing, and circulation; intubate as clinically indicated |
| Give one dose only of activated charcoal (1 g/kg; standard adult dose is 50 g) without additives |
| Avoid additional serotonergic agents |
| Treat seizures with benzodiazepines (eg, lorazepam 1 to 2 mg IV every five minutes as needed) |
| Treat prolonged QRS interval with sodium bicarbonate: 1 to 2 meq/kg IV push; if QRS narrows with bicarbonate bolus, infuse bicarbonate: approximately 133 meq NaHCO3 in one liter D5W, at 250 mL/hour in adults, or twice maintenance fluid infusion rate in children |
| Observe patients with prolonged QTc for development of torsades |
| Treat torsades with magnesium sulfate (Mg): initial dose 2 g IV over two minutes; may repeat after 10 minutes; infusion may be needed |
| For management of serotonin syndrome, see separate UpToDate topic |
Reference:
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