The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity

Background: There are difficulties with the diagnosis of serotonin toxicity, particularly with the use of Sternbach’s criteria. Aim: To improve the criteria for diagnosing clinically significant serotonin toxicity. Design: Retrospective analysis of prospectively collected data Methods: We studied all patients admitted to the Hunter Area Toxicology Service (HATS) following an overdose of a serotonergic drug from January 1987 to November 2002 (n = 2222). Main outcomes were: diagnosis of serotonin toxicity by a clinical toxicologist, fulfilment of Sternbach’s criteria and treatment with a serotonin receptor (5-HT2A) antagonist. A learning dataset of 473 selective serotonin reuptake inhibitor (SSRI)-alone overdoses was used to determine individual clinical features predictive of serotonin toxicity by univariate analysis. Decision rules using CART analysis were developed, and tested on the dataset of all serotonergic overdose admissions. Results: Numerous clinical features were associated with serotonin toxicity, but only clonus (inducible, spontaneous or ocular), agitation, diaphoresis, tremor and hyperreflexia were needed for accurate prediction of serotonin toxicity as diagnosed by a clinical toxicologist. Although the learning dataset did not include patients with life-threatening serotonin toxicity, hypertonicity and maximum temperature > 38°C were universal in such patients; these features were therefore added. Using these seven clinical features, decision rules (the Hunter Serotonin Toxicity Criteria) were developed. These new criteria were simpler, more sensitive (84% vs. 75%) and more specific (97% vs. 96%) than Sternbach’s criteria. Discussion: These redefined criteria for serotonin toxicity should be more sensitive to serotonin toxicity and less likely to yield false positives.