Rosen & Barkin's 5-Minute Emergency Medicine Consult (562 page)

• Ipecac has no utility in the ED.
  
• Administer activated charcoal in almost every toxic ingestion that presents within 1 hr with a patent airway
  
• Never use multiple doses of cathartic in conjunction with multiple-dose activated charcoal.
  

• Albertson TE, Owen KP, Sutter ME, et al. Gastrointestinal decontamination in the acutely poisoned patient.
  Int J Emerg Med.
  2011;4:65.
  
• Holstege CP, Dopmeier SG, Bechtel LK. Critical Care Toxicology Emergency Medicine Clinics of North America – Volume 26, Issue 3 (August 2008).
  
• Isbister GK, Kumar VV. Indications for single-dose activated charcoal administration in acute overdose.
  Curr Opin Crit Care
  . 2011;17(4):351—357.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Poisoning
  
• Poisoning, Antidotes
  
• Poisoning, Toxidromes
  

CODES

977.9 Poisoning by unspecified drug or medicinal substance

BASICS

• A toxidrome is the constellation of signs and symptoms that result from the effects of a particular toxin (toxic syndrome)
  
• Mechanism of action varies with each class of toxin to which the patient may be exposed and the target receptors.
  

DIAGNOSIS

Toxidromes

• There are multiple toxidromes:
  
  • Anticholinergic
    
  • Cholinergic
    
  • Sympathomimetic
    
  • Hallucinogenic
    
  • Opiate
    
  • Sedative–hypnotic
    
  • Withdrawal syndromes
    
  • Serotonin syndrome
    
  • Malignant neuroleptic syndrome
    
• Anticholinergic:
  Mnemonic:
  “Blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone”:
  
  • Hyperthermia (“hot as a hare)
    
  • Dry, flushed skin (“dry as a bone” and “red as a beet”)
    
  • Dilated pupils (“blind as a bat”)
    
  • Delirium (“mad as a hatter”)
    
  • Tachycardia (“the heart runs alone”)
    
  • Hypertension
    
  • Hyperthermia
    
  • Urgency retention (“bowel and bladder lose their tone”)
    
  • Decreased bowel sounds (“bowel and bladder lose their tone”)
    
  • Seizures
    
  • Mental status changes
    
  • Somnolence
    
• Cholinergic:
  Mnemonic:
  DUMBELS for the muscarinic component:
  
  • Muscarinic signs:
    
    • D
      iarrhea, diaphoresis
      
    • U
      rination
      
    • M
      iosis
      
    • B
      radycardia, bronchorrhea, bronchospasm (the killer Bs)
      
    • E
      mesis
      
    • L
      acrimation
      
    • S
      alivation
      
  • Nicotinic signs:
    
    • Mydriasis
      
    • Tachycardia
      
    • Weakness
      
    • Hypertension
      
    • Fasciculations
      
• Sympathomimetic:
  Similar to anticholinergic presentation except for skin and bowel differences (diaphoresis and increased bowel sounds may be present in sympathomimetic presentations):
  
  • Diaphoresis
    
  • Mydriasis
    
  • Tachycardia
    
  • Hypertension
    
  • Hyperthermia
    
  • Seizures
    
  • Increased peristalsis
    
• Hallucinogenic:
  May have significant overlap with sympathomimetic toxidrome as many sympathomimetic drugs have hallucinogenic properties (e.g., MDMA/ecstasy, cathinones, hallucinogenic amines). Other hallucinogens include LSD, psilocybin, peyote, mescaline:
  
  • Disorientation
    
  • Hallucinations
    
  • Anxiety
    
  • Panic
    
  • Seizures
    
• Opiate:
  
  • Classic triad:
    
    • Miosis
      
    • Hypoventilation
      
    • Coma
      
  • May also present with:
    
    • Bradycardia
      
    • Hypotension
      
    • Hypothermia
      
    • Decreased bowel sounds
      
• Sedative–hypnotics and alcohol:
  
  • Sedation
    
  • Mental status changes (confusion, delirium, hallucinations)
    
  • Vision changes (blurred vision, diplopia)
    
  • Slurred speech
    
  • Ataxia
    
  • Nystagmus
    
• Withdrawal
  (alcohol, benzodiazepine, barbiturates):
  
  • Mydriasis
    
  • Tachycardia
    
  • Hypertension
    
  • Hyperthermia
    
  • Increased respiratory rate
    
  • Diaphoresis
    
  • Increased bowel sounds
    
  • Tremor
    
  • Agitation
    
  • Anxiety
    
  • Hallucinations
    
  • Confusion
    
  • Seizures
    
• Withdrawal
  (opioid):
  
  • Nausea
    
  • Vomiting
    
  • Diarrhea
    
  • Abdominal cramps
    
  • Increased bowel sounds
    
  • Mydriasis
    
  • Piloerection
    
  • Tachycardia
    
  • Lacrimation
    
  • Salivation
    
  • Hypertension
    
  • Yawning
    
• Neuroleptic malignant syndrome:
  
  • Recent treatment with typical and atypical antipsychotic medications:
    
    • Generally occurs from hours to several weeks of starting or increasing the dose of a medication, but can occur at any time.
      
  • Hyperthermia
    
  • Muscular rigidity
    
  • Diaphoresis
    
  • Mental status changes
    
  • Hypertension or hypotension may be seen
    
  • Sialorrhea
    
  • Tremor
    
  • Incontinence
    
  • Increased creatinine phosphokinase
    
  • Leukocytosis
    
  • Metabolic acidosis
    
• Serotonin syndrome:
  
  • Occurs soon after the increase in dose or addition of serotonergic medications.
    
  • Syndrome with variable presentation
    
  • Following are most common, seen 25–57% of the time:
    
    • Mental status changes (confusion, agitation, hypomania, lethargy)
      
    • Seizures
      
    • Myoclonus
      
    • Hyperreflexia
      
    • Muscle rigidity
      
    • Tremor
      
    • Nystagmus
      
    • Hyperthermia
      
    • Diaphoresis
      
    • Tachycardia
      
    • Hypertension
      
    • Mydriasis
      

• Bradycardia:
  
  • α
    ₂
    -adrenergic agonists (e.g., clonidine)
    
  • β-blockers
    
  • Calcium-channel blockers
    
  • Digoxin and related substances
    
  • Cholinergics
    
  • Opioids
    
• Tachycardia:
  
  • Sympathomimetics
    
  • Anticholinergics
    
  • Methylxanthines
    
  • Tricyclic antidepressant
    
  • Withdrawal
    
  • Phenothiazines
    
  • Atypical antipsychotics
    
  • α
    ₁
    -blockade with reflex tachycardia
    
  • Phosphodiesterase type 5 inhibitor (e.g., Sildenafil)
    
• Hyperthermia:
  
  • Anticholinergics
    
  • Sympathomimetics
    
  • Serotonin syndrome
    
  • Neuroleptic malignant syndrome
    
  • Malignant hyperthermia
    
  • Dinitrophenol
    
  • Salicylates
    
  • Withdrawal
    
• Hypothermia:
  
  • Carbon monoxide
    
  • Oral hypoglycemics
    
  • Opiates
    
  • Ethanol
    
  • Sedative–hypnotics
    
  • α
    ₂
    -adrenergic agonists
    
• Hypertension:
  
  • Sympathomimetics
    
  • Anticholinergics
    
  • Nicotine
    
  • Phencyclidine (PCP)
    
  • Ergot alkaloids
    
• Hypotension:
  
  • α
    ₂
    -agonists
    
  • α
    ₁
    -antagonists
    
  • β-blockers
    
  • Calcium-channel blockers
    
  • Angiotensin converting–enzyme inhibitors
    
  • Methylxanthines
    
  • Nitrates
    
  • Opioids
    
  • Phenothiazines
    
  • Phosphodiesterase type 5 inhibitors
    
  • Sedative–hypnotics
    
  • Ethanol
    
  • Tricyclic antidepressants
    
  • Atypical antipsychotic medications
    
• Miosis:
  
  • Cholinergics
    
  • Clonidine
    
  • Reserpine
    
  • Phenothiozines
    
  • Atypical antipsychotics
    
• Mydriasis:
  
  • Anticholinergics
    
  • Sympathomimetics
    
  • Withdrawal (esp. opioids)
    
  • Botulism
    
• Seizures:
  Mnemonic with a limited list of causes for toxic seizures
  OTIS CAMPBELL:
  
  • O
    rganophosphates
    
  • T
    ricyclic antidepressants
    
  • I
    soniazid, insulin
    
  • S
    ympathomimetics, salicylates
    
  • C
    amphor, cocaine, citalopram
    
  • A
    mphetamines, anticholinergic agents
    
  • M
    ethylxanthines (theophylline, caffeine), mushrooms (
    Gyromitra:
    monomethyl hydrazine group), meperidine
    
  • P
    CP, propoxyphene, plants (nicotine, water hemlock)
    
  • B
    enzodiazepine withdrawal, bupropion
    
  • E
    thanol withdrawal
    
  • L
    ithium, lidocaine
    
  • L
    ead, lindane
    
• Diaphoresis:
  
  • Sympathomimetics
    
  • Cholinergics
    
  • Salicylates
    
  • Withdrawal
    
  • Serotonin syndrome
    
• Bradypnea:
  
  • Opiates
    
  • Sedative–hypnotics
    
  • Ethanol
    
  • γ-hydroxybutyric acid and congeners
    
  • Botulism
    
  • Muscular receptor blockade
    
• Tachypnea:
  
  • Paraquat (and other drugs that cause pneumonitis)
    
  • Salicylates
    
  • Sympathomimetics
    
  • Dinitrophenol
    
  • Methylxanthines
    
  • Drugs that cause acidosis