Serotonin Syndrome ma Fa'alavelave Fa'alavelave Fa'alavelave Fa'afuase'i¶

Serotonin syndrome and neuroleptic malignant syndrome (NMS) are life-threatening medication emergencies where prescription drugs, over-the-counter cough suppressants, herbal supplements, or recreational substances trigger runaway central nervous system instability, severe muscle stiffness or twitching, and dangerously high core body temperatures above 40.0 degrees Celsius (104.0 degrees Fahrenheit). While serotonin syndrome explodes rapidly within 2 to 24 hours of taking a new medication, increasing a dose, or combining two serotonergic agents, neuroleptic malignant syndrome typically develops more gradually over 1 to 14 days after starting or increasing an antipsychotic or anti-nausea medication that blocks dopamine receptors.

Your immediate priorities during a suspected severe drug interaction are to summon advanced paramedic transport, halt all further administration of every medication and supplement, initiate aggressive external evaporative and ice-pack cooling if the person is burning hot, protect the airway during seizures or severe rigidity, and assemble every pill bottle and pharmacy printout so emergency physicians can administer targeted chemical antidotes immediately upon hospital arrival.

Fai nei loa¶

1. Call emergency medical services immediately: Call your local emergency number (911 in the United States and Canada, 112 across the European Union, 999 in the United Kingdom, 000 in Australia) or consult our directory of numera fa'afuase'i. In the United States, you can also call Poison Control at 1-800-222-1222 once an ambulance is en route. Report suspected serotonin syndrome or neuroleptic malignant syndrome with fever and muscle rigidity.
2. Stop all medications, supplements, and over-the-counter remedies immediately: Do not give another dose of any antidepressant, pain medication, migraine triptan, cough syrup, anti-nausea pill, or herbal supplement. Never attempt to treat the fever with over-the-counter acetaminophen (paracetamol), ibuprofen, or aspirin.
3. Measure temperature and begin aggressive external cooling if hot: If the person feels hot to the touch, is sweating profusely, or has a temperature above 38.5 degrees Celsius (101.3 degrees Fahrenheit), strip off heavy clothing, mist their bare skin with cool water while fanning them vigorously, and place cloth-wrapped ice packs in the armpits, groin, and sides of the neck.
4. Position safely on their side and never restrain twitching limbs: Help the agitated or rigid person lie on their side in the recovery position on a padded floor or bed away from hard edges. Never hold down, sit on, or forcefully restrain limbs that are jerking, trembling, or rigid, as isometric struggling against physical restraint rapidly accelerates fatal muscle breakdown and spikes core body heat.
5. Gather every medication container, patch, and supplement bottle: Collect all prescription bottles, blister packs, transdermal patches (check the skin on the back, chest, arms, and thighs for fentanyl, selegiline, or rivastigmine patches), over-the-counter cold remedies, herbal teas, and illicit substances into a single plastic bag for paramedics.
6. Monitor breathing and prepare for CPR or seizure care: Stay beside the person continuously. If a generalized seizure occurs, cushion their head and roll them onto their side once jerking subsides. If they become unresponsive and stop breathing normally, begin cardiopulmonary resuscitation (CPR) vave.

flowchart TD
    Start["Sudden Agitation, Fever, Sweating, and Muscle Stiffness or Twitching After Medication Use"] --> Call["1. Call Emergency Services (911 / 112 / 999) and Stop All Medications Immediately"]
    Call --> CheckTemp{"2. Is Skin Burning Hot or Core Temp Over 38.5 C (101.3 F)?"}
    CheckTemp -->|Yes| CoolNow["Strip Clothing, Mist Skin with Cool Water, Fan Vigorously, Place Ice Packs at Groin and Armpits"]
    CheckTemp -->|No| MonitorTemp["Keep Room Cool at 18 to 20 C (64 to 68 F), Remove Blankets, Check Temp Every 5 Minutes"]
    CoolNow --> NeuroSign{"3. Examine Muscle Tone and Reflex Pattern"}
    MonitorTemp --> NeuroSign
    NeuroSign -->|Rhythmic Ankle Jerks, Shivering, Wide Pupils, Fast Onset Under 24 Hours| SS["Suspect Serotonin Syndrome: Avoid Restraint, Protect from Falls, Gather Serotonergic Meds"]
    NeuroSign -->|Lead Pipe Stiffness Everywhere, Slow Reflexes, Onset Over Days| NMS["Suspect Neuroleptic Malignant Syndrome: Check Antipsychotics or Anti-Nausea Drugs, Cool Body"]
    SS --> Airway{"4. Is the Person Conscious and Protecting Their Airway?"}
    NMS --> Airway
    Airway -->|Conscious but Agitated| Calm["Dim Lights, Speak Calmly, NeverGive Fever Reducers or Fluids by Mouth if Swallowing Is Impaired"]
    Airway -->|Unconscious or Seizing| Recovery["Roll into Side-Lying Recovery Position, Cushion Head, Begin CPR if Breathing Stops"]

Differentiating serotonin syndrome, neuroleptic malignant syndrome, and other toxic hyperthermias¶

When a patient develops acute confusion, fever, racing heart rate, and abnormal muscle tone after taking medications, emergency clinicians must rapidly distinguish between four life-threatening toxidromes: serotonin syndrome, neuroleptic malignant syndrome (NMS), anticholinergic toxicity, and sympathomimetic overdose. While prehospital first aid for all four centers on airway protection, stopping the offending agent, and rapid physical cooling, observing the specific pattern of muscle movement, skin moisture, pupil size, and bowel sounds gives paramedics and emergency physicians critical diagnostic head-start data.

Understanding the Hunter Serotonin Toxicity Criteria and high-risk drug combinations¶

Serotonin (5-hydroxytryptamine, or 5-HT) is a neurotransmitter that regulates mood, thermoregulation, gastrointestinal motility, vascular tone, and motor reflexes. Serotonin syndrome (also called serotonin toxicity) is rarely caused by a normal therapeutic dose of a single antidepressant; instead, the World Health Organization (WHO), the United States Food and Drug Administration (FDA), and the United Kingdom Medicines and Healthcare products Regulatory Agency (MHRA) emphasize that critical toxicity most often strikes when two or more medications that boost serotonin through different biochemical mechanisms are combined, or when a patient switches between antidepressants without observing a mandatory washout period.

The five serotonergic mechanisms that collide¶

1. Inhibition of serotonin reuptake from the synaptic cleft: Selective serotonin reuptake inhibitors (SSRIs such as fluoxetine, sertraline, escitalopram, citalopram, paroxetine), serotonin-norepinephrine reuptake inhibitors (SNRIs such as venlafaxine, duloxetine, desvenlafaxine), tricyclic antidepressants (TCAs such as amitriptyline, clomipramine, imipramine), certain synthetic opioid painkillers (tramadol, meperidine/pethidine, fentanyl, methadone, tapentadol), the over-the-counter cough suppressant dextromethorphan (DXM), the herbal supplement St. John's wort (Hypericum perforatum), and the muscle relaxant cyclobenzaprine.
2. Inhibition of serotonin breakdown by monoamine oxidase (MAOIs): Psychiatric MAOIs (phenelzine, tranylcypromine, isocarboxazid, moclobemide), Parkinson disease MAO-B inhibitors (selegiline, rasagiline), the hospital and oral antibiotic linezolid (which is a potent reversible MAOI), and the intravenous surgical dye methylene blue.
3. Increased presynaptic release of stored serotonin: Amphetamines, dextroamphetamine, methylphenidate, methamphetamine, cocaine, MDMA (ecstasy / Molly), and high-dose decongestants.
4. Direct stimulation of postsynaptic serotonin receptors: Migraine triptans (sumatriptan, rizatriptan, zolmitriptan), ergot alkaloids (dihydroergotamine), buspirone, lithium, and hallucinogens (LSD).
5. Increased serotonin synthesis from dietary precursors: High-dose L-tryptophan or 5-HTP (5-hydroxytryptophan) nutritional supplements marketed for sleep or mood support.

Common household medication traps that trigger serotonin syndrome¶

• The "Cold and Cough Syrup" trap: A person taking a daily SSRI or SNRI for depression or anxiety catches a winter cold and takes an over-the-counter multi-symptom cough and cold medicine containing dextromethorphan (DXM). Because DXM strongly blocks serotonin reuptake and often shares the same liver enzyme pathway (CYP2D6) as the antidepressant, serotonin levels surge within hours.
• The "Post-Injury Painkiller" trap: A patient on sertraline or duloxetine visits an urgent care clinic for back pain or a fracture and is prescribed tramadol or cyclobenzaprine, or uses leftover opioid pain pills alongside their regular antidepressant.
• The "Infection Antibiotic" trap: A patient taking any antidepressant or Parkinson medication is prescribed the antibiotic linezolid for a methicillin-resistant Staphylococcus aureus (MRSA) skin or lung infection. Because linezolid blocks monoamine oxidase from breaking down serotonin, combining it with an SSRI or SNRI causes severe, often fatal serotonin syndrome.
• The "Washout Period" trap: A patient stops taking fluoxetine (Prozac) and starts an MAOI or another high-potency serotonergic agent a few days later. Because fluoxetine and its active metabolite (norfluoxetine) have an extraordinarily long biological half-life, clinicians require a minimum 5-week washout period after stopping fluoxetine (and at least 2 weeks after stopping other SSRIs, SNRIs, or MAOIs) before introducing a conflicting medication.

How to check for the Hunter Serotonin Toxicity Criteria at the bedside¶

Emergency toxicologists worldwide use the Hunter Serotonin Toxicity Criteria (which are 84 percent sensitive and 97 percent specific, outperforming older checklists) to identify serotonin syndrome in anyone who has taken a serotonergic agent within the past 5 weeks. A person meets the criteria if they exhibit any one of the following five clinical sign clusters:

1. Spontaneous clonus: Continuous, rhythmic, involuntary jerking or pulsing of a muscle group (especially the feet, ankles, or jaw) occurring without anyone touching the limb.
2. Inducible clonus PLUS agitation OR profuse sweating (diaphoresis): When you gently but briskly push the ball of the person's foot upward toward their shin (dorsiflexion) and hold gentle pressure, the foot and ankle rhythmically bounce back and forth against your hand more than 3 or 4 times (inducible ankle clonus), accompanied by either mental agitation or soaking sweat.
3. Ocular clonus PLUS agitation OR profuse sweating: When you ask the person to look straight ahead or follow your finger to the side, their eyeballs exhibit slow, continuous, roving side-to-side oscillations ("ping-pong gaze") or rapid rhythmic jerks, accompanied by agitation or sweating.
4. Tremor PLUS hyperreflexia: Visible rhythmic shaking of the hands and legs combined with bounding, hyperactive knee and ankle reflexes.
5. Hypertonia (stiff muscles) PLUS fever above 38.0 degrees Celsius (100.4 degrees Fahrenheit) PLUS either ocular clonus OR inducible clonus: This fifth cluster represents life-threatening severe serotonin toxicity requiring immediate cooling and intensive care intubation.

Recognizing neuroleptic malignant syndrome (NMS) and Parkinson withdrawal crisis¶

While serotonin syndrome is driven by excess serotonin overstimulating nerve junctions, neuroleptic malignant syndrome (NMS) is caused by a sudden, catastrophic starvation of dopamine signaling in two key regions of the brain: the nigrostriatal pathway (which controls smooth skeletal muscle movement, leading to extreme rigidity when blocked) and the anterior hypothalamus (which regulates core body temperature and autonomic blood pressure).

Two distinct pathways into neuroleptic malignant syndrome¶

1. Dopamine receptor blockade (Classic NMS): Triggered by starting, increasing the dose of, or combining medications that block D2 dopamine receptors. While high-potency first-generation antipsychotics (haloperidol, fluphenazine, chlorpromazine) carry the highest risk, second-generation atypical antipsychotics (risperidone, olanzapine, quetiapine, paliperidone, aripiprazole, clozapine) also cause NMS. Crucially, many non-psychiatric patients develop NMS from dopamine-blocking anti-nausea and stomach motility drugs commonly kept at home for gastroenteritis, migraines, or gastroparesis, including metoclopramide, prochlorperazine, promethazine, and droperidol.
2. Dopamine agonist withdrawal (Parkinsonism-Hyperpyrexia Syndrome): Triggered when a patient with Parkinson disease or restless legs syndrome suddenly stops taking, runs out of, or cannot swallow their daily dopamine-replacement medications (levodopa/carbidopa, pramipexole, ropinirole, rotigotine patches, or amantadine), such as during a stomach flu or hospitalization. Deprived of exogenous dopamine within 18 to 72 hours, the patient's brain plunges into an identical state of lead-pipe rigidity, high fever, and autonomic collapse.

The classic tetrad of neuroleptic malignant syndrome¶

NMS typically unfolds in a recognizable sequence over 24 to 72 hours:

• 1. Altered mental status (often the earliest sign): Before fever appears, the patient becomes unusually quiet, mute (akinetic mutism), confused, dazed, or catatonic, staring blankly and failing to respond to questions, or alternating with terrified agitation and delirium.
• 2. Generalized "lead-pipe" muscular rigidity: When you gently try to bend or straighten the person's elbow, wrist, or knee, the limb resists movement with a heavy, uniform, unyielding stiffness throughout the entire range of motion, exactly like bending a solid lead pipe. If a superimposed tremor is present, it feels like ratcheting a stiff gear (cogwheel rigidity). Rigidity of the throat and jaw muscles (dysphagia and dysarthria) makes speech slurred and causes thick saliva to pool and drool from the mouth.
• 3. Hyperthermia: Core body temperature climbs above 38.5 degrees Celsius (101.3 degrees Fahrenheit) and frequently exceeds 40.0 to 41.5 degrees Celsius (104.0 to 106.7 degrees Fahrenheit) as locked skeletal muscles burn adenosine triphosphate (ATP) continuously.
• 4. Autonomic nervous system instability: The body's internal autopilot loses control: heart rate races above 110 to 140 beats per minute, blood pressure swings wildly from dangerously high to shockingly low within minutes, breathing becomes rapid and shallow (tachypnea), the skin is drenched in greasy sweat (diaphoresis), and the person may experience sudden urinary incontinence.

Step-by-step first aid while waiting for paramedics¶

Because both serotonin syndrome and neuroleptic malignant syndrome kill through the same three terminal cascades (thermal brain damage from core temperatures above 41 degrees Celsius / 105.8 degrees Fahrenheit, suffocation from rigid chest wall muscles or aspiration, and cardiac arrest from potassium released by dissolving muscle tissue), your field care must be systematic and immediate.

Step 1: Immediate thermal rescue (Active evaporative and conductive cooling)¶

If the person's skin feels hot, flushed, or sweaty, or if an oral, tympanic (ear), or forehead thermometer reads above 38.5 degrees Celsius (101.3 degrees Fahrenheit), every minute of delay allows core temperature to climb higher.

1. Strip away insulation: Immediately remove blankets, comforters, jackets, sweaters, socks, and heavy pants down to underwear. Move the person away from sunny windows or radiators into the coolest room available, and set air conditioning to maximum.
2. Apply continuous evaporative cooling (mist and fan): Evaporative cooling is the fastest safe method inside a home when an ice bath is unavailable or unsafe due to agitation or seizure risk. Use a clean plant spray bottle or wet washcloths to mist or sponge the person's bare chest, abdomen, arms, and thighs with cool or lukewarm water (15 to 20 degrees Celsius / 59 to 68 degrees Fahrenheit) while aiming an electric box fan or oscillating fan directly across their wet skin (or fanning them vigorously with a stiff piece of cardboard or baking sheet). Moving air evaporates the water film, pulling large amounts of latent heat out of cutaneous blood vessels without causing severe shivering.
3. Apply targeted conductive ice packs: Wrap ice packs, bags of frozen vegetables, or resealable plastic bags filled with ice cubes and a cup of water inside thin wet dish towels. Pack them snugly against the major superficial arteries:
4. Both sides of the neck (carotid arteries, taking care never to press on the windpipe).
5. Both armpits (axillary arteries).
6. Both sides of the groin (femoral arteries).
7. Target stopping temperature: Recheck temperature every 5 minutes if possible. Once core temperature drops down to 38.0 degrees Celsius (100.4 degrees Fahrenheit), remove the ice packs and stop misting so you do not overshoot into hypothermia.

Step 2: Safe positioning and the strict prohibition against physical restraint¶

Patients in severe serotonin toxicity or NMS are frequently delirious, frightened, thrashing, or experiencing violent rhythmic muscle jerking (myoclonus).

• Clear the environment instead of restraining the body: Move coffee tables, chairs, lamps, and sharp objects away from the person. Surround them with couch cushions, pillows, or folded blankets on the floor so that if their legs jerk or they roll, they strike soft padding rather than hard furniture.
• Reduce sensory stimulation: Bright overhead lights, loud voices, television noise, and sudden physical touch trigger startle reflexes that worsen clonus and muscle spasms. Dim the room lights, turn off televisions and radios, and have a single calm person speak in a slow, quiet, reassuring voice.
• Use the side-lying recovery position: If the person is drowsy, mute, drooling, or rigid, roll them gently onto their side. In neuroleptic malignant syndrome, throat rigidity prevents normal swallowing; lying flat on the back allows pooled saliva or vomit to drain straight into the lungs, causing fatal aspiration pneumonia or asphyxiation. Use a clean cloth wrapped around your finger to wipe drool from the lower corner of their mouth.

Step 3: Fluid rules and airway vigilance¶

• Never give fluids, food, or pills by mouth: Even if the person appears awake, severe tremor, jaw clonus, or pharyngeal lead-pipe rigidity makes choking extremely likely. Do not attempt to make them drink water or sports drinks to treat dehydration; paramedics will establish intravenous (IV) lines to infuse cooled isotonic crystalloid fluids safely.
• Exception for Parkinson withdrawal only (under medical direction): If a patient with known Parkinson disease developed NMS solely because they missed their scheduled levodopa doses and is still fully alert and able to swallow safely, ask the emergency dispatcher or on-call neurologist whether their missed dose should be given or crushed for hospital nasogastric administration. Never force pills into the mouth of a drowsy or drooling patient.
• Watch chest wall excursion: Severe rigidity in NMS or late-stage serotonin syndrome can lock the intercostal muscles between the ribs and the diaphragm (chest wall rigidity), preventing the chest from expanding. Watch the bare chest closely; if breaths become shallow, gasping, or slow (under 10 breaths per minute), or if the lips turn blue-gray, alert the dispatcher immediately and prepare to perform rescue breathing and CPR.

Comprehensive medication audit: what to collect for paramedics¶

Emergency physicians cannot choose between cyproheptadine (for serotonin syndrome), dantrolene and bromocriptine (for neuroleptic malignant syndrome), or physostigmine (for anticholinergic poisoning) without knowing every substance that entered the patient's body over the preceding 14 to 35 days. While one person stays beside the patient cooling and protecting their airway, assign a second person to complete this rapid audit:

• Check the patient's bare skin for transdermal patches: Inspect the upper back, shoulder blades, chest, upper arms, hips, and thighs. Look for clear or tan adhesive patches delivering fentanyl (pain), selegiline (depression), rotigotine (Parkinson disease), rivastigmine (dementia), or scopolamine (nausea). If the patient is burning hot with suspected toxicity from a fentanyl, selegiline, or scopolamine patch, peel it off using a gloved hand or towel (folding the sticky sides together and placing it in a bag for paramedics), as hot skin increases transdermal drug absorption by up to 300 percent. Never remove a rotigotine Parkinson patch, as removing dopamine replacement worsens NMS.
• Salu potu moe, faleta'ele, taga, ma ato mo fagu uma: Fa'aputu fagu talavai uma, fa'atulaga fualaau fa'alevaiaso, ma lisiti fale talavai, e aofia ai vaila'au na taofi i totonu o le 5 vaiaso talu ai.
• Collect all over-the-counter (OTC) products: Look specifically for liquid cough syrups, gelcaps labeled "DM" (dextromethorphan), nighttime sleep aids, antihistamines, motion sickness pills, and migraine powders.
• Collect herbal, dietary, and bodybuilding supplements: Look for St. John's wort, 5-HTP, L-tryptophan, SAM-e (S-adenosyl-L-methionine), ginseng, synephrine / bitter orange, yohimbine, weight-loss thermogenics, and pre-workout powders.
• Document exact timeline and dose changes: Write down on a piece of paper:
• Did any doctor start a new prescription or increase a milligram dose in the last 14 days?
• Did the patient run out of or abruptly stop any psychiatric or Parkinson medication in the last 7 days?
• O le a le taimi na ave ai le tui mulimuli i le aso, ma e mafai ona tupu se faʻalavelave faʻalua poʻo se faʻalavelave faʻafuaseʻi?

Complications: rhabdomyolysis, kidney failure, and disseminated intravascular coagulation¶

Understanding why hospitals treat severe drug interaction hyperthermia as a top-tier resuscitation priority helps families recognize why even mild or moderate symptoms require emergency department evaluation:

1. Rhabdomyolysis and acute hyperkalemic cardiac arrest: When skeletal muscle fibers are forced to contract or twitch continuously for hours at temperatures above 39.5 degrees Celsius (103.1 degrees Fahrenheit), the muscle cell membranes rupture and dissolve (exertional and drug-induced rhabdomyolysis). Ruptured muscle cells dump massive quantities of potassium (causing lethal heart arrhythmias within minutes), creatine kinase (CK), and myoglobin (a dark red-brown protein that plugs the microscopic filtering tubules of the kidneys, causing acute kidney failure and dark brown "cola-colored" urine).
2. Metabolic acidosis: Exhausted muscles switch to anaerobic metabolism, flooding the blood with lactic acid until blood pH drops below levels compatible with normal cardiac contractility.
3. ** Fa'asalalauina o le toto toto (DIC):** O le vevela i luga a'e o le 40.5 i le 41.0 tikeri Celsius (104.9 i le 105.8 tikeri Fahrenheit) e fa'ate'aina polotini endothelial o lo'o ufiufi ai a'a toto, ma fa'aosoina ai le faitau afe o pa'u toto ninii i le tino atoa a'o fa'avauvau uma vaega fa'a'ala'au, fa'ato'a fa'ao'o atu i vaega o le fa'apalapala IV.

Prevention checklists for patients and caregivers¶

Once a person recovers from serotonin syndrome or neuroleptic malignant syndrome, or if they take daily psychiatric, neurological, or chronic pain medications, following strict pharmacy safeguards prevents recurrence:

• Use one single pharmacy for every prescription: Filling prescriptions at a single pharmacy chain allows the pharmacist's automated drug-interaction software to flag dangerous serotonergic or dopamine-blocking combinations across different prescribing specialists (such as a psychiatrist, a pain clinic physician, and a dentist).
• Ask the "Serotonin Question" before buying any cold or pain remedy: Before purchasing any over-the-counter cough syrup, allergy pill, or herbal supplement, show your medication list to the pharmacist and ask explicitly: *"Does this product contain dextromethorphan or anything that interacts with my antidepressant?"*Choose plain guaifenesin, saline nasal sprays, or honey drops instead of "DM" cough suppressants.
• Never stop Parkinson or antipsychotic medications abruptly: Always refill prescriptions at least 7 days before running out, and pack a 5-day emergency reserve in your go-bag evacuation pack ma emergency contact card.
• Seek early evaluation for mild "prodromal" warning signs: Mild serotonin excess often starts with new hand tremors, unexplained sweating at rest, diarrhea, restlessness, and twitching feet before fever ever develops. Calling the prescribing doctor or visiting an urgent clinic at the tremor stage allows safe dose adjustment before a full crisis erupts.

Fesili e fai soo¶

Punavai ua siaki¶

• Boyer EW, Shannon M (New England Journal of Medicine Clinical Practice Review): The Serotonin Syndrome and Hunter Serotonin Toxicity Criteria (Dunkley EJC et al., QJM).
• United States Food and Drug Administration (FDA, United States): FDA Drug Safety Communications on Serotonin Syndrome with SSRIs, SNRIs, Triptans, Opioids (Fentanyl, Tramadol), and Methylene Blue / Linezolid.
• United Kingdom Medicines and Healthcare products Regulatory Agency (MHRA) and National Institute for Health and Care Excellence (NICE, United Kingdom): Drug Safety Updates on Serotonin Syndrome and Neuroleptic Malignant Syndrome Recognition and Management.
• American Psychiatric Association (APA) and Neuroleptic Malignant Syndrome Information Service (NMSIS, United States): International Consensus Diagnostic Criteria and Treatment Guidelines for Neuroleptic Malignant Syndrome.
• American College of Medical Toxicology (ACMT) and Poison Control Centers (United States): Toxicologic Hyperthermia, Cyproheptadine Administration, and Prehospital Evaporative Cooling Protocols.
• World Health Organization (WHO) and International Federation of Red Cross and Red Crescent Societies (IFRC, International): Emergency Triage of Acute Poisoning, Drug Overdose, and Seizure First Aid Guidelines.

Taiala fa'atatau¶

• Poisoning and medication overdose first aid
• Rhabdomyolysis fa'amalositino, manu'a tuga o fatuga'o, ma maso malepe
• Faoa ma tetete fesoasoani muamua
• Ta'i vevela fa'asaga i fa'atonuga fa'amalieina o le vaivai o le vevela
• Numera o fa'alavelave fa'afuase'i ile atunu'u