Serotonin syndrome
ICD-10 G90.81 is a billable code used to indicate a diagnosis of serotonin syndrome.
Serotonin syndrome is a potentially life-threatening condition resulting from excessive serotonergic activity in the central nervous system. It is often precipitated by the use of serotonergic medications, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and certain recreational drugs. Clinically, serotonin syndrome is characterized by a triad of symptoms: cognitive effects (such as confusion and agitation), autonomic instability (including hyperthermia, tachycardia, and hypertension), and neuromuscular abnormalities (such as tremors, rigidity, and hyperreflexia). The onset of symptoms can occur within hours of medication initiation or dose increase, making timely recognition and intervention critical. Diagnosis is primarily clinical, relying on the identification of symptoms and a thorough medication history. Treatment typically involves discontinuation of the offending agent, supportive care, and, in severe cases, the use of serotonin antagonists. Understanding the interplay between serotonin syndrome and other nervous system disorders, such as autonomic dysregulation and pain syndromes, is essential for effective management and coding.
Detailed medication history, including dosages and duration of use.
Patients presenting with agitation, confusion, and autonomic instability after medication adjustments.
Consideration of polypharmacy and interactions with other psychiatric medications.
Comprehensive assessment of vital signs, neurological status, and medication history.
Patients presenting with acute changes in mental status and autonomic dysfunction.
Rapid assessment and intervention are critical; documentation must reflect urgency.
Used when a patient presents with severe symptoms of serotonin syndrome.
Document the severity of symptoms and treatment provided.
Emergency medicine providers must ensure rapid assessment and intervention.
Key symptoms include cognitive changes (confusion, agitation), autonomic instability (hyperthermia, tachycardia), and neuromuscular abnormalities (tremors, rigidity).
