TOXIDROMES. Searching for Clues HISTORY When to suspect Approach to known exposure Approach to unknown exposure.

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TOXIDROMES

TOXIDROMESSearching for Clues

HISTORYWhen to suspectApproach to known exposureApproach to unknown exposurePHYSICAL EXAMINATIONVSEye examSkinNeuro

APPROACH TO TREATMENTEarly and effective decontaminationSupportive therapyAntidotesEnhanced eliminationLABORATORY EXAMAnion gap, acid-base status, osmolar gapBUN/creat, UAECGAbd filmCXRToxicology screenTOXIC SYNDROMES AND DRUG OVERDOSAGESPhysiologic stimulantsPhysiologic depressantsOther drug overdosages

PHYSIOLOGIC STIMULANTSAnticholinergicsSympathomimetics (ex. cocaine)HallucinogensDrug withdrawalMiscellaneous (thyroid hormones)ANTICHOLINERGICSANTIHISTAMINESANTIPSYCHOTICSBELLADONNA ALKALOIDSCYCLIC ANTIDEPRESSANTCYCLOBENZAPRINEPARKINSONS DZ DRUGSGI/GU ANTISPASMODICSMYDRIATRICSPLANTS/ MUSHROOMSANTICHOLINERGICS: ATROPINECLINICAL PRESENTATIONHot as a hare, dry as a bone, mad as a hatterDryness of mouthflushed, hot, dry skindilated and nonreactive pupilstachycardiahallucinations, restlessness

ANTICHOLINERGIC: ATROPINETREATMENTGut decontaminationPhysostigmineSupportive careCOCAINECLINICAL PRESENTATIONtachycardia, HTN arrhythmiacan get hypotension and reflex bradycardiaCNS stimulationCOCAINETREATMENTCNS sedationLabetololTreat hyperthermia?Parlodel or desipramineHallucinogensStimulation of serotoninergic systemIllusions, visual hallucinations, sweating, tachycardia, pupillary dilatationUsu done in 12 hoursNo true withdrawal stateHallucinogensTreatmentGenerally do not require medical treatmentCan use benzodiazepine for agitationReduce stimuliDiscontinuation can result in dysphoria from reduced serotonin activity. SSRI can be used for 3-6 monthsPHYSIOLOGIC DEPRESSANTSCholinergicsNarcoticsSymphatholytics (cyclic antidepressants)Sedative-hypnoticsMiscellaneous (carbon monoxide)CHOLINERGICSBETHANACOLCARBAMATE INSECTICIDESMYASTHENIA GRAVIS DRUGSEDROPHONIUMPHYSOSTIGMINEPILOCARPINENICOTINECHOLINERGICS: CLINICAL PRESENTATIONDEFECATIONURINATIONMIOSISBRONCHO- CONSTRICTIONBRADYCARDIAEMESISLACRIMATIONSALIVATION

CHOLINERGICSTREATMENTGastric decontaminationRespiratory supportAtropinePralidoximeCardiac monitoringTx seizures with benzodiazipineOPIATESCLINICAL PRESENTATIONPinpoint pupilsRespiratory depressionBradycardiaHypotensionHypothermiaPulmonary edemaSeizures

OPIATESTREATMENTAcuteNaloxoneChronicMethadoneCatapresNaltrexoneOPIATESPOSSIBLE COMPLICATIONSAspirationPulmonary edemaWithdrawal symptomsNeed for repeated doses

BENZODIAZIPINESCLINICAL PRESENTATIONRespiratory depressionDrowsinessComaBENZODIAZIPINESTREATMENTGenerally requires no pharmacologic interventionFlumazenilCYCLIC ANTIDEPRESSANTSCLINICAL PRESENTATIONMost are combination anticholinergic and sympatholyticComaSeizuresHypotensionCardiac dysrhythmias

CYCLIC ANTIDEPRESSANTSTREATMENTGastric decontaminationTreat cardiac dysrhythmiasTreat seizuresCarbon Monoxide PoisoningMost common cause of death by poisoningSymptoms vary:Mild: HA, mild dyspneaMod: HA, dizziness, N/V,dyspnea, irritabilitySevere: Coma, seizures, CV collapse

28Carbon Monoxide PoisoningMost common cause of death by poisoningSymptoms vary:Mild: HA, mild dyspneaMod: HA, dizziness, N/V, dyspnea, irritabilitySevere: Coma, seizures, CV collapse

29OTHER DRUGSDISSOCIATIVE DRUGSACETOMINOPHENSALICYLATESDIGOXIN

SEROTONIN SYNDROMELITHIUMCLUB DRUGS

DISSOCIATIVE DRUGSKetamine, Phenycyclidine (PCP), Phenylcyclohexylpyrolidine (PHP)Acts on all six neurotransmitter systemsAnticholinergic: dry skin, miosisDopamine/norepinephrine:agitation, delusionsOpioid:pain perception alterationsSerotonin: perceptual changesGABA receptor inhibition: excitation

DISSOCIATIVE DRUGSTreatmentHaloperidolPresynaptic dopamine antagonistShifts the dopamine-acetylcholine activity ratio in the limbic systemTherefore can counteract the dopamine stimulation and cholinergic antagonism of the drugACETAMINOPHENCLINICAL PRESENTATIONNo specific symptoms or signsACETAMINOPHENTREATMENTGastric decontaminationN-acetylcysteineSALICYLATESCLINICAL PRESENTATIONMixed acid-base disturbancesGI: N/V, abdominal painCNS: tinnitus, lethargy seizures, cerebral edema, irritabilityResp: pulmonary edemaCoagulation abnormalitiesDIGOXINCLINICAL PRESENTATIONNausea/vomitingMental status changesCardiovascular symptomsDIGOXINTREATMENTGastric decontaminationFab fragmentsSEROTONIN SYNDROMECLINICAL PRESENTATIONNeurobehavioral: mental status changes, agitation, confusion, seizuresAutonomic: hyperthermia, diaphoresis, diarrhea, tachycardia, HTN, salivationNeuromuscular: myoclonus, hyperreflexia, tremor, muscle rigiditySEROTONIN SYNDROMETREATMENTRespiratory supportTemperature controlSedativesMuscle relaxantsLITHIUMSymptomsGI: vomiting, diarrheaNeuro: tremors, confusion, dysarthria, vertigo, choreoathetosis, ataxia, hyperreflexia, seizures, opisthotonis, and comaLabs: decreased anion gapTreatmentLevels >2.5 meq/LGastric lavageUrinary alkalinizationNot very effectiveAminophyllineHemodialysis>3.5 mEq/L (acute)>2.5 w/ chronic ingestion or renal insufficiency

CLUB DRUGSRave parties increasing in popularityDrugs meant to intensify sensory experience of lights/music, facilitate prolonged dancing

MDMA EctasyStructurally resembles amphetamine (stimulant) and mescaline (hallucinogen)SX: trismus, bruxism, tachycardia, mydriasis, diaphoresis, hyperthermia, hyponatremia, hepatic failure, CV toxicity (tachycardia, HTN)TreatmentMainly supportiveBenzodiazepinesCalm environmentAvoid beta-blockersCan result in unopposed alpha effectIf essential consider labetololGHB: Date rape drug Georgia homeboy, liquid ectasy, or grievous bodily harmDeveloped as anesthetic agent. GABA analogSymptomsBradycardiaHypothermia hypoventilationSomnolenceVomitingMyoclonic jerkingTreatmentConservative mgmtIntubationCareful exam for sexual assaultKetamine: K, special KDeveloped as an anesthetic, structurally resemble PCPSymptomsNystagmusTachycardiaHTNvomitingTreatmentBenzodiazepinesSupportive careIVCan consider urine alkalinizationCLINICAL SCENARIO 1A 48 year old unconscious woman is brought to the hospital. She is convulsing and has an odor of garlic on her breath. She is incontinent for urine and stool. On exam her VS: T99, HR50, RR24, BP146/88. Skin is diaphoretic. She is drooling. Pupils are constricted. Lungs diffuse wheezing.

CLINICAL SCENARIO 1Recognize: Cholinergic poisoningTreatment:Gastric decontaminationRespiratory supportCardiac monitoring Atropine followed by pralidoxime Treat seizures with benzodiazepineCLINICAL SCENARIO 217 year old male presents to the hospital with somnolence, slurred speech, and combative behavior. His younger sister said he showed her a handful of small seeds that he was going to take. On exam his VS: T102, HR120, BP100/60, RR22. Skin is hot and dry. Mucous membranes are dry. Pupils are dilated and not reactive.CLINICAL SCENARIO 2Recognize: Anticholinergic poisoningTreatment Supportive carePhysostigmineComaArrythmiasSevere HTNSeizures CLINICAL SCENARIO 326 y/o male presents unresponsive. His friend accompanies him and states he took a handful of pills because he was in pain. On exam his VS: T96, HR40, RR6, BP50/30. Pupils are 3mm.CLINICAL SCENARIO 3Recognize: Opioid poisoningTreatmentNaloxone

SummaryDont panic!!Recognize your cluesLook for the toxidrome syndrome

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