A 42-year-old female is brought to the ED by EHS with acute confusion and agitation following an intentional ingestion. The presentation is consistent with a diagnosis of serotonin syndrome, complicated by hyperthermia and status epilepticus.

Goals and objectives

The aim of this case is for learners to develop a rapid management and diagnostic approach to the patient presenting with altered mental status and an elevated temperature.

1. Demonstrate an initial approach to the acutely altered patient, prioritizing the primary survey.
2. Develop an appropriate differential diagnosis for the “hot and altered” patient.
3. Differentiate between hyperthermia and a fever.
4. Identify the intentional ingestion of prescribed medications and recognize the presentation as serotonin syndrome.
5. Differentiate serotonin syndrome from neuroleptic malignant syndrome and other toxidromes that can cause hyperthermia.
6. Identify potential complications of serotonin syndrome and work up appropriately.
7. Initiate supportive management of serotonin syndrome through rehydration, active cooling, and agitation management.
8. Review indications, administration, and availability of cyproheptadine.
9. Review techniques for actively cooling a hyperthermic patient.