SEROTONIN SYNDROME (SS)
Related to increased serotonin synthesis or release or decreased serotonin metabolism. Common drugs: SSRI, SNRI, trazodone, opioids, buspirone, metoclopramid, MAOI
60% start within 6 hours of starting a drug or increasing dose
3 key elements: autonomic instability (inc. temp, inc bp, inc hr &rr, diaphoresis and mydriasis), Neuromuscular signs (tremor, myoclonus, hyperreflexia) and cognitive changes (hypervigilance, startle, agitation)
none
Taper offending drug, benzodiazepams for tremor
Not hyperthermic and hypertonic like NMS, not flushed skin, dry mouth like AchS

NEUROLEPTIC SYNDROME (NMS)
Caused by typical and atypical antipsychotics (dopamine antagonists), metoclopramide or stopping of parkinson’s medication
Occurs within one week of starting the drug or increasing dose
4 key elements:
rigidity, abnormal mental status, autonomic instability, and hyperthemia. Look for myoclonus and dysarthria
Elevated cpk and leukocytosis
Stop offending drug, hydration and dantrolene if high fever present
Look for rigidity, akinesia, and diaphoresis to distinguish from serotonin and anticholinergic toxicity

ANTICHOLINERGIC SYNDROME (AchS)
Excessive anticholinergic activity due to medication: Common drugs: meclizine, scopolamine, antihistamines, oxycodone, diltiazem, digoxin, zantac, TCA, oxybutynin, hyoscyamine, and many more.
Usually a gradual onset in a geriatric population
Decreased secretions, flushed face, dry mouth, constipation, urinary retention, mydriasis with blurred vision, hyperthermia, rapid HR, ataxia, myotonic twitching, sedation, cognitive slowing with confusion or delirium
No specific labs
Stop offending medications, hydration and physostigmine if severe

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