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ER52 Emergency Medicine
Toxicology
Toronto Notes 2019
Table 32. Specific Toxidromes
Toxidrome
Anticholinergic
Cholinergic
Extrapyramidal
Hemoglobin Derangements
Opioid, Sedative/ Hypnotic,
EtOH
Sympathomimetic
Serotonin Syndrome
Overdose Signs and Symptoms
Examples of Drugs
Antidepressants (e.g. TCAs) Cyclobenzaprine (Flexeril®) Carbamazepine
Antihistamines (e.g. diphenhydramine) Antiparkinsonians
Antipsychotics
Antispasmodics
Belladonna alkaloids (e.g. atropine)
Natural plants: mushrooms, trumpet flower Anticholinesterases: physostigmine Insecticides (organophosphates, carbamates) Nerve gases
Major tranquilizers Antipsychotics
CO poisoning (carboxyhemoglobin)
Drug ingestion (methemoglobin, sulfmethemoglobin)
EtOH
Benzodiazepines
Opioids (morphine, heroin, fentanyl, etc.) Barbiturates
GHB (“G,” “liquid gold”)
Amphetamines, caffeine, cocaine, LSD, phencyclidine
Ephedrine and other decongestants Thyroid hormone
Sedative or EtOH withdrawal
MAOI, TCA, SSRI, opiate analgesics
Cough medicine, weight reduction medications
Hyperthermia
Dilated pupils
Dry skin
Vasodilation Agitation/hallucinations Ileus
Urinary retention Tachycardia
“Hot as a hare”
“Blind as a bat”
“Dry as a bone”
“Red as a beet”
“Mad as a hatter”
“The bowel and bladder lose their tone and the heart goes on alone”
“DUMBELS”
Diaphoresis, Diarrhea, Decreased BP Urination
Miosis
Bronchospasm, Bronchorrhea, Bradycardia Emesis, Excitation of skeletal muscle Lacrimation
Salivation, Seizures
Dysphonia, dysphagia
Rigidity and tremor
Motor restlessness, crawling sensation (akathisia) Constant movements (dyskinesia)
Dystonia (muscle spasms, laryngospasm, trismus, oculogyric crisis, torticollis)
Increased respiratory rate Decreased LOC
Seizures
Cyanosis unresponsive to O2 Lactic acidosis
Hypothermia
Hypotension
Respiratory depression
Dilated or constricted pupils (pinpoint in opioid) CNS depression
Increased temperature
CNS excitation (including seizures) Tachycardia, HTN
N/V
Diaphoresis
Dilated pupils
Mental status changes, autonomic hyperactivity, neuromuscular abnormalities, hyperthermia, diarrhea, HTN
Note: ASA poisoning and hypoglycemia mimic sympathomimetic toxidrome
F – Full Vitals, ECG Monitor, Foley, X-Rays G – Give Specific Antidotes and Treatments
Urine Alkalinization Treatment for ASA Overdose
• urinepH>7.5
• fluidresuscitatefirst,then3ampsNaHCO3/LofD5Wat1.5xmaintenance • add20-40mEq/LKClifpatientisabletourinate
Table 33. Protocol for Warfarin Overdose
INR Management: Consider Prothrombin Complex Concentrate (Octaplex®, Beriplex®) for any elevated INR, AND either life-threatening bleeding, or a plan for the patient to undergo a surgical procedure within the next 6 h
<5.0 Cessation of warfarin administration, observation, serial INR/PT
5.1–9.0 If no risk factors for bleeding, hold warfarin x 1-2 d and reduce maintenance dose OR
Vitamin K 1-2 mg PO if patient at increased risk of bleeding
9.1–20.0 Hold warfarin, vitamin K 2-4 mg PO, serial INR/PT, additional vitamin K if necessary >20.0 Hold warfarin, vitamin K 10 mg IV over 10 min, increase vitamin K dosing (q4h) if needed