See also

Poisoning – Acute guidelines for initial management 
Serotonin Syndrome 
Serotonin and Noradrenaline Re-uptake Inhibitors (SNRIs) Poisoning Guideline

Key points

1. SSRI poisoning is usually benign and many children and young people are asymptomatic
2. Possible symptoms include nausea and less commonly seizures and cardiac dysrhythmias.  Children and young people should also be assessed for serotonin syndrome
3. Remember that venlafaxine and desvenlafaxine are serotonin and noradrenaline re-uptake inhibitors [SNRIs] NOT SSRIs, and overdose is potential life-threatening with a risk of delayed seizures, hypotension and cardiac dysrhythmias (See SNRI poisoning guideline) 

For 24 hour advice, contact Victorian Poisons Information Centre 13 11 26 

Background

Deliberate or accidental self-poisoning with selective serotonin re-uptake inhibitors [SSRIs] is common and usually follows a benign course. SSRIs are commonly used in the treatment of depression, anxiety and obsessive compulsive disorder in both children and adults.

Patients requiring assessment

• All children and young people with deliberate self-poisoning
• Ingestion of an unknown quantity
• Any symptomatic child or young person
• Children who have accidentally ingested doses greater than threshold for assessment

Risk Assessment

Dose requiring medical assessment in paediatric accidental ingestions

*Note these values do not apply to adolescents or adults please discuss with toxicologist

History and Examination

• Clarify the drugs ingested (including co-ingestants and formulations).
• Ascertain the amounts ingested and when the ingestion occurred.
• Children and young people who have co-ingested other serotonergic agents are at significantly greater risk of serotonin syndrome (including monoamine oxidase inhibitors, tramadol or serotonin and noradrenaline re-uptake inhibitors [SNRIs]) 

Initial Symptoms

• Overdose is usually benign irrespective of dose and many children and young people remain asymptomatic.
• Symptoms usually begin within 4 hours of consumption and resolve within 12 hours.
• Mild symptoms of serotonin toxicity occur in less than 20% of children and young people.
• Nausea is common.

Physical examination

• Evaluate for serotonin syndrome, it can range from mild symptoms to a life-threatening syndrome.
• Examination is usually unremarkable; infrequently drowsiness, tremor, tachycardia and vomiting can occur.
• Seizures are uncommon occurring in 2-4% (treat with benzodiazepines).
• Citalopram or escitalopram overdose can cause cardiac dysrhythmias (wide complex bradycardia and torsade de pointes).
• SSRI overdose does not commonly cause coma or significantly reduced level of consciousness and this suggests co-ingestion or an alternate cause.
• Always check for Medicalert bracelet in any unconscious patient, or any other signs of underlying medical condition (fingerprick marks etc).

Investigations

12 lead ECG, blood glucose and paracetamol concentration in deliberate self-poisoning.
Cardiac monitoring and serial ECG if large citalopram or escitalopram ingestion, duration of monitoring will depend on ingestion quantity (discuss with toxicologist).

Acute Management

Supportive care

Serotonin syndrome can be treated with titrated intravenous benzodiazepines (discuss with toxicologist)
Treat seizures with benzodiazepines
Cardiac monitoring if large citalopram or escitalopram ingestion
Observation for 12 hours is recommended based on the pharmacokinetics of the individual SSRIs

Decontamination

• SSRI intoxication has an excellent outcome and activated charcoal is rarely indicated 
• If large ingestion of citalopram or escitalopram discuss with toxicologist as activated charcoal may be recommended

Consider consultation with local paediatric team when

• Children and young people with accidental ingestion can be observed at home if asymptomatic and ingested dose is less than threshold for assessment
• Observation for 12 hours is recommended in children and young people with deliberate self-poisoning or accidental ingestion where the ingested dose is greater than threshold for assessment
• Children and young people with symptoms usually only require supportive care for 12-24 hours and can be safely discharged when clinical features of SSRI intoxication resolve
• Children and young people with citalopram or escitalopram intoxication require on-going cardiac monitoring if QTc abnormal

Contact Victorian Poisons Information Centre 13 11 26 for advice 

When to consider transfer

Children and young people who develop severe serotonin syndrome should be managed in PICU

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

Consider discharge when

Normal GCS
Normal ECG
Period of observation as above
For deliberate ingestion a risk assessment should indicate that the patient is at low risk of further self harm in the discharge setting

Discharge information and follow-up

Accidental ingestion: Parent information sheet from Victorian Poisons Information centre on the prevention of poisoning  

Intentional self-harm: Referral to local mental health services e.g. Orygen Youth Health: 1800 888 320   

Recreational poisoning: Referral to YoDAA, Victoria's Youth Drug and Alcohol Advice service: 1800 458 685  

Last updated November 2017