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Toxidrome Overview

Quinton Taylor

Toxidrome Agent Symptoms Antidote

Insecticides (e.g. organophosphates)

physostigmine, neostigmine, pyridostigmine, pilocarpine,

nerve agents (e.g. Sarin)

Muscarinic: Defecation, Urination, Miosis, Bradycardia, Bronchosecretions, Emesis, Lacrimation, Salivation, Sweating (DUMBBELLS)

Nicotinic: Mydriasis, Tachycardia, Weakness, Hypertension, Fasciculations (MTWtHF)

Atropine (with pralidoxime if organophosphate poisoning)
Anticholinergic Antihistamines, antipsychotics, antidepressants (TCAs), anti-parkinsons, atropine, scopolamine Hyperthermia, dry skin, mydriasis, delirium, hallucinations, tachycardia, urinary retention, seizures (“Hot as a hare, red as a beet, dry as a bone, blind as a bat, mad as a hatter”)

Supportive care, consider

physostigmine with toxicology

Sympathomimetic Cocaine, amphetamines, bath salts, synthetic cannabinoids, sedative/hyponotic withdrawal, pseudoephedrine, caffeine Hyperthermia, mydrasis, diaphoresis, tachycardia, arrythmias, hypertension, seizures None, supportive care; benzodiazepines as needed\*
Opioid Morphine, heroin, hydromorphone, fentanyl Miosis, hypoventilation, somnolence, comatose, bradycardia, hypotension Naloxone
Sedative-hypnotic Benzos, barbiturates, alcohol, zolpidem CNS depression, confusion, stupor, coma None, supportive care only
Hallucinogenic Phencyclidine, LSD, MDMA “Ecstasy” Hallucinations, depersonalization, agitation, mydriasis (usually), tachycardia, hypertension, nystagmus None, supportive care only
Serotonin syndrome SSRIs, SNRIs, MOAIs Hyperreflexia, myoclonus, diaphoresis, flushing, diarrhea, hyperthermia, tachycardia, confusion, agitation, coma Supportive care; benzodiazepines as needed\*; contact toxicology prior to using cyproheptadine
*for treatment of seizures, tachycardia, hypertension, agitation, and hyperthermia

General Workup

  • ABCs, evaluate vital signs, mental status, pupil size, skin temperature and moisture

  • Pulse ox, continuous cardiac monitoring, EKG, blood glucose

  • UDS, acetaminophen/salicylate levels, ethanol levels, UA, BMP, hepatic function panel, blood gas

General Management

  • Decontamination for topical exposures

  • Antidotes if known ingestions/fits appropriate toxidrome

  • Supportive care

  • Discuss with toxicology, may be ways to enhance elimination of the toxin (e.g. diuresis, alkalinization, dialysis, etc.)