TOXIDROMES
HISTORYWhen to suspectApproach to known exposureApproach to unknown exposure
PHYSICAL EXAMINATIONVSEye examSkinNeuro
APPROACH TO TREATMENTEarly and effective decontaminationSupportive therapyAntidotesEnhanced elimination
LABORATORY EXAMAnion gap, acid-base status, osmolar gapBUN/creat, UAECGAbd filmCXRToxicology screen
TOXIC SYNDROMES AND DRUG OVERDOSAGES
Physiologic stimulantsPhysiologic depressantsOther drug overdosages
PHYSIOLOGIC STIMULANTSAnticholinergicsSympathomimetics (ex. cocaine)HallucinogensDrug withdrawalMiscellaneous (thyroid hormones)
ANTICHOLINERGICSANTIHISTAMINESANTIPSYCHOTICSBELLADONNA ALKALOIDSCYCLIC ANTIDEPRESSANTCYCLOBENZAPRINE
PARKINSON’S DZ DRUGSGI/GU ANTISPASMODICSMYDRIATRICSPLANTS/ MUSHROOMS
ANTICHOLINERGICS: ATROPINE
CLINICAL PRESENTATION
“Hot as a hare, dry as a bone, mad as a hatter”Dryness of mouthflushed, hot, dry skindilated and nonreactive pupilstachycardiahallucinations, restlessness
ANTICHOLINERGIC: ATROPINE
TREATMENTGut decontaminationPhysostigmineSupportive care
COCAINECLINICAL PRESENTATION
tachycardia, HTN arrhythmiacan get hypotension and reflex bradycardiaCNS stimulation
COCAINETREATMENT
CNS sedationLabetololTreat hyperthermia?Parlodel or desipramine
HallucinogensStimulation of serotoninergic systemIllusions, visual hallucinations, sweating, tachycardia, pupillary dilatationUsu done in 12 hoursNo true withdrawal state
HallucinogensTreatment
Generally 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 months
PHYSIOLOGIC DEPRESSANTS
CholinergicsNarcoticsSymphatholytics (cyclic antidepressants)Sedative-hypnoticsMiscellaneous (carbon monoxide)
CHOLINERGICSBETHANACOLCARBAMATE INSECTICIDESMYASTHENIA GRAVIS DRUGSEDROPHONIUMPHYSOSTIGMINE
PILOCARPINENICOTINE
CHOLINERGICS: CLINICAL PRESENTATION
DEFECATIONURINATIONMIOSISBRONCHO- CONSTRICTIONBRADYCARDIAEMESISLACRIMATIONSALIVATION
CHOLINERGICSTREATMENT
Gastric decontaminationRespiratory supportAtropinePralidoximeCardiac monitoringTx seizures with benzodiazipine
OPIATESCLINICAL PRESENTATION
Pinpoint pupilsRespiratory depressionBradycardiaHypotensionHypothermiaPulmonary edemaSeizures
OPIATESTREATMENT
AcuteNaloxone
ChronicMethadoneCatapresNaltrexone
OPIATESPOSSIBLE COMPLICATIONS
AspirationPulmonary edemaWithdrawal symptomsNeed for repeated doses
BENZODIAZIPINESCLINICAL PRESENTATIONRespiratory depressionDrowsinessComa
BENZODIAZIPINESTREATMENT
Generally requires no pharmacologic interventionFlumazenil
CYCLIC ANTIDEPRESSANTSCLINICAL PRESENTATION
Most are combination anticholinergic and sympatholyticComaSeizuresHypotensionCardiac dysrhythmias
CYCLIC ANTIDEPRESSANTSTREATMENT
Gastric decontaminationTreat cardiac dysrhythmiasTreat seizures
Carbon Monoxide Poisoning
Most common cause of death by poisoningSymptoms vary:
Mild: HA, mild dyspneaMod: HA, dizziness, N/V,dyspnea, irritabilitySevere: Coma, seizures, CV collapse
Carbon Monoxide Poisoning
Most common cause of death by poisoningSymptoms vary:
Mild: HA, mild dyspneaMod: HA, dizziness, N/V, dyspnea, irritabilitySevere: Coma, seizures, CV collapse
OTHER DRUGSDISSOCIATIVE DRUGSACETOMINOPHENSALICYLATESDIGOXIN
SEROTONIN SYNDROMELITHIUM“CLUB DRUGS”
DISSOCIATIVE DRUGSKetamine, Phenycyclidine (PCP), Phenylcyclohexylpyrolidine (PHP)Acts on all six neurotransmitter systems
Anticholinergic: dry skin, miosisDopamine/norepinephrine:agitation, delusionsOpioid:pain perception alterationsSerotonin: perceptual changesGABA receptor inhibition: excitation
DISSOCIATIVE DRUGSTreatment
HaloperidolPresynaptic dopamine antagonistShifts the dopamine-acetylcholine activity ratio in the limbic systemTherefore can counteract the dopamine stimulation and cholinergic antagonism of the drug
ACETAMINOPHENCLINICAL PRESENTATION
No specific symptoms or signs
ACETAMINOPHENTREATMENT
Gastric decontaminationN-acetylcysteine
SALICYLATESCLINICAL PRESENTATION
Mixed acid-base disturbancesGI: N/V, abdominal painCNS: tinnitus, lethargy seizures, cerebral edema, irritabilityResp: pulmonary edemaCoagulation abnormalities
DIGOXINCLINICAL PRESENTATION
Nausea/vomitingMental status changesCardiovascular symptoms
DIGOXINTREATMENT
Gastric decontaminationFab fragments
SEROTONIN SYNDROMECLINICAL PRESENTATION
Neurobehavioral: mental status changes, agitation, confusion, seizuresAutonomic: hyperthermia, diaphoresis, diarrhea, tachycardia, HTN, salivationNeuromuscular: myoclonus, hyperreflexia, tremor, muscle rigidity
SEROTONIN SYNDROMETREATMENT
Respiratory supportTemperature controlSedativesMuscle relaxants
LITHIUMSymptoms
GI: vomiting, diarrheaNeuro: tremors, confusion, dysarthria, vertigo, choreoathetosis, ataxia, hyperreflexia, seizures, opisthotonis, and comaLabs: decreased anion gap
TreatmentLevels >2.5 meq/LGastric lavageUrinary alkalinization
Not very effective
AminophyllineHemodialysis
>3.5 mEq/L (acute)>2.5 w/ chronic ingestion or renal insufficiency
“CLUB DRUGS”Rave parties increasing in popularityDrugs meant to intensify sensory experience of lights/music, facilitate prolonged dancing
MDMA “Ectasy”Structurally resembles amphetamine (stimulant) and mescaline (hallucinogen)SX: trismus, bruxism, tachycardia, mydriasis, diaphoresis, hyperthermia, hyponatremia, hepatic failure, CV toxicity (tachycardia, HTN)
TreatmentMainly supportiveBenzodiazepinesCalm environmentAvoid beta-blockers
Can result in unopposed alpha effectIf essential consider labetolol
GHB: Date rape drug “Georgia homeboy, liquid ectasy, or
grievous bodily harm”
Developed as anesthetic agent. GABA analogSymptoms
BradycardiaHypothermia hypoventilationSomnolenceVomitingMyoclonic jerking
TreatmentConservative mgmtIntubationCareful exam for sexual assault
Ketamine: “K”, “special K”Developed as an anesthetic, structurally resemble PCPSymptoms
NystagmusTachycardiaHTNvomiting
TreatmentBenzodiazepinesSupportive careIVCan consider urine alkalinization
CLINICAL 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 benzodiazepine
CLINICAL 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 carePhysostigmine
ComaArrythmiasSevere 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 poisoningTreatment
Naloxone
SummaryDon’t panic!!Recognize your cluesLook for the toxidrome syndrome
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