When should I consider referring a patient with serotonin syndrome to secondary care?

Consider referring a patient with serotonin syndrome to secondary care if they present with moderate to severe symptoms, including marked autonomic instability (such as high fever, tachycardia, or labile blood pressure), significant neuromuscular abnormalities (severe rigidity, clonus, or hyperreflexia), altered mental status (confusion, agitation, or coma), or if there is diagnostic uncertainty or failure to improve with initial management in primary care. Immediate referral is warranted if the patient shows signs of life-threatening complications such as hyperthermia above 40°C, seizures, or rhabdomyolysis. Patients with suspected serotonin syndrome who have ingested multiple serotonergic agents or overdose should also be referred urgently for specialist assessment and monitoring ¹ (Nelson et al., 2007).

In primary care, mild cases with stable vital signs and mild symptoms may be managed initially by stopping serotonergic drugs and supportive care, but close monitoring is essential. If symptoms worsen or do not resolve promptly, escalation to secondary care is necessary. Specialist advice should be sought if there is any uncertainty about diagnosis or management ¹ (Nelson et al., 2007).