TOXIDROMES

Patricia Evans, M.D.

Georgetown University-Providence
Hospital Family Practice Residency
Searching for Clues
 HISTORY
When to suspect
Approach to known exposure
Approach to unknown exposure
 PHYSICAL EXAMINATION
VS
Eye exam
Skin
Neuro
 LABORATORY EXAM
Anion gap, acid-base status, osmolar
gap
BUN/creat, UA
ECG
Abd film
CXR
Toxicology screen
APPROACH TO TREATMENT
Early and effective decontamination
Supportive therapy
Antidotes
Enhanced elimination
 TOXIC SYNDROMES AND
DRUG OVERDOSAGES
Physiologic stimulants
Physiologic depressants
Other drug overdosages
PHYSIOLOGIC STIMULANTS
Anticholinergics
Sympathomimetics (ex. cocaine)
Hallucinogens
Drug withdrawal
Miscellaneous (thyroid hormones)
 ANTICHOLINERGICS
ANTIHISTAMINES PARKINSON’S DZ
ANTIPSYCHOTICS DRUGS
BELLADONNA GI/GU
ALKALOIDS ANTISPASMODICS
CYCLIC MYDRIATRICS
ANTIDEPRESSANT PLANTS/
CYCLOBENZAPRINE MUSHROOMS
 ANTICHOLINERGICS:
ATROPINE
CLINICAL
PRESENTATION
“Hot as a hare, dry as a
bone, mad as a hatter”
Dryness of mouth
flushed, hot, dry skin
dilated and nonreactive
pupils
tachycardia
hallucinations,
restlessness
 ANTICHOLINERGIC:
ATROPINE
TREATMENT
Gut decontamination
Physostigmine
Supportive care
 COCAINE
CLINICAL PRESENTATION
tachycardia, HTN arrhythmia
can get hypotension and reflex bradycardia
CNS stimulation
 COCAINE
TREATMENT
CNS sedation
Labetolol
Treat hyperthermia
?Parlodel or desipramine
 Hallucinogens
Stimulation of serotoninergic system
Illusions, visual hallucinations,
sweating, tachycardia, pupillary
dilatation
Usu done in 12 hours
No true withdrawal state
 Hallucinogens
Treatment
Generally do not require medical treatment
Can use benzodiazepine for agitation
Reduce stimuli
Discontinuation can result in dysphoria
from reduced serotonin activity. SSRI can
be used for 3-6 months
PHYSIOLOGIC DEPRESSANTS
Cholinergics
Narcotics
Symphatholytics (cyclic antidepressants)
Sedative-hypnotics
Miscellaneous (carbon monoxide)
 CHOLINERGICS
BETHANACOL PILOCARPINE
CARBAMATE NICOTINE
INSECTICIDES
MYASTHENIA
GRAVIS DRUGS
EDROPHONIUM
PHYSOSTIGMINE
CHOLINERGICS: CLINICAL
PRESENTATION
DEFECATION
URINATION
MIOSIS
BRONCHO-
CONSTRICTION
BRADYCARDIA
EMESIS
LACRIMATION
SALIVATION
 CHOLINERGICS
TREATMENT
Gastric decontamination
Respiratory support
Atropine
Pralidoxime
Cardiac monitoring
Tx seizures with benzodiazipine
 OPIATES
CLINICAL
PRESENTATION
Pinpoint pupils
Respiratory
depression
Bradycardia
Hypotension
Hypothermia
Pulmonary edema
Seizures
 OPIATES
TREATMENT
Acute
Naloxone
Chronic
Methadone
Catapres
Naltrexone
 OPIATES
POSSIBLE COMPLICATIONS
Aspiration
Pulmonary edema
Withdrawal symptoms
Need for repeated doses
 BENZODIAZIPINES
CLINICAL PRESENTATION
Respiratory depression
Drowsiness
Coma
 BENZODIAZIPINES
TREATMENT
Generally requires no pharmacologic
intervention
Flumazenil
CYCLIC ANTIDEPRESSANTS
CLINICAL PRESENTATION
Most are combination anticholinergic and
sympatholytic
Coma
Seizures
Hypotension
Cardiac dysrhythmias
CYCLIC ANTIDEPRESSANTS
TREATMENT
Gastric decontamination
Treat cardiac dysrhythmias
Treat seizures
Carbon Monoxide Poisoning
Most common cause of death by
poisoning
Symptoms vary:
Mild: HA, mild dyspnea
Mod: HA, dizziness, N/V,dyspnea, irritability
Severe: Coma, seizures, CV collapse
Carbon Monoxide Poisoning
Most common cause of death by
poisoning
Symptoms vary:
Mild: HA, mild dyspnea
Mod: HA, dizziness, N/V, dyspnea,
irritability
Severe: Coma, seizures, CV collapse
 OTHER DRUGS
DISSOCIATIVE SEROTONIN
DRUGS SYNDROME
ACETOMINOPHEN LITHIUM
SALICYLATES “CLUB DRUGS”
DIGOXIN
 DISSOCIATIVE DRUGS
Ketamine, Phenycyclidine (PCP),
Phenylcyclohexylpyrolidine (PHP)
Acts on all six neurotransmitter systems
Anticholinergic: dry skin, miosis
Dopamine/norepinephrine:agitation, delusions
Opioid:pain perception alterations
Serotonin: perceptual changes
GABA receptor inhibition: excitation
 DISSOCIATIVE DRUGS
Treatment
Haloperidol
Presynaptic dopamine antagonist
Shifts the dopamine-acetylcholine activity ratio
in the limbic system
Therefore can counteract the dopamine
stimulation and cholinergic antagonism of the
drug
 ACETAMINOPHEN
CLINICAL PRESENTATION
No specific symptoms or signs
 ACETAMINOPHEN
TREATMENT
Gastric decontamination
N-acetylcysteine
 SALICYLATES
CLINICAL PRESENTATION
Mixed acid-base disturbances
GI: N/V, abdominal pain
CNS: tinnitus, lethargy seizures, cerebral
edema, irritability
Resp: pulmonary edema
Coagulation abnormalities
 DIGOXIN
CLINICAL PRESENTATION
Nausea/vomiting
Mental status changes
Cardiovascular symptoms
 DIGOXIN
TREATMENT
Gastric decontamination
Fab fragments
 SEROTONIN SYNDROME
CLINICAL PRESENTATION
Neurobehavioral: mental status changes,
agitation, confusion, seizures
Autonomic: hyperthermia, diaphoresis,
diarrhea, tachycardia, HTN, salivation
Neuromuscular: myoclonus, hyperreflexia,
tremor, muscle rigidity
 SEROTONIN SYNDROME
TREATMENT
Respiratory support
Temperature control
Sedatives
Muscle relaxants
 LITHIUM
Symptoms Treatment
GI: vomiting, diarrhea Levels >2.5 meq/L
Neuro: tremors, Gastric lavage
confusion, dysarthria,
vertigo, choreoathetosis,
Urinary alkalinization
ataxia, hyperreflexia, Not very effective
seizures, opisthotonis, Aminophylline
and coma Hemodialysis
Labs: decreased anion >3.5 mEq/L (acute)
gap >2.5 w/ chronic
ingestion or renal
insufficiency
 “CLUB DRUGS”
Rave parties
increasing in
popularity
Drugs meant to
intensify sensory
experience of
lights/music,
facilitate prolonged
dancing
 MDMA “Ectasy”
Structurally resembles Treatment
amphetamine
(stimulant) and Mainly supportive
mescaline Benzodiazepines
(hallucinogen) Calm environment
SX: trismus, bruxism,
Avoid beta-blockers
tachycardia, mydriasis,
diaphoresis, Can result in
hyperthermia, unopposed alpha
effect
hyponatremia, hepatic
failure, CV toxicity If essential consider
(tachycardia, HTN) labetolol
 GHB: Date rape drug
“Georgia homeboy, liquid ectasy, or grievous
bodily harm”
Developed as anesthetic Treatment
agent. GABA analog Conservative mgmt
Symptoms Intubation
Bradycardia
Careful exam for
Hypothermia
sexual assault
hypoventilation
Somnolence
Vomiting
Myoclonic jerking
 Ketamine: “K”, “special K”
Developed as an Treatment
anesthetic, Benzodiazepines
structurally resemble Supportive care
PCP IV
Symptoms Can consider urine
Nystagmus alkalinization
Tachycardia
HTN
vomiting
 CLINICAL SCENARIO 1
A 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 1
Recognize: Cholinergic poisoning
Treatment:
Gastric decomtamination
Respiratory support
Cardiac monitoring
Atropine followed by pralidoxime
Treat seizures with benzodiazepine
 CLINICAL SCENARIO 2
17 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: T100,
HR120, BP100/60, RR22. Skin is warm and
dry. Mucous membranes are dry. Pupils are
dilated and not reactive.
 CLINICAL SCENARIO 2
Recognize: Anticholinergic poisoning
Treatment
Supportive care
Physostigmine
Coma
Arrythmias
Severe HTN
Seizures
 CLINICAL SCENARIO 3
26 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 3
Recognize: Opioid poisoning
Treatment
Naloxone
 Summary
Don’t panic!!
Recognize your
clues
Look for the
toxidrome syndrome