Toxidromes
Steven E. Aks, DO, FACMT
Toxidromes are clinical syndromes that are essential for
the successful recognition of poisoning patterns. A toxidrome is the constellation
of signs and symptoms that suggest a specific class of poisoning. The most
important toxidromes, clinically, are:
-
Sympathomimetic
-
Sedative Hypnotic
-
Opiate
-
Anticholinergic
-
Cholinergic
What are toxins that cause:
1. Coma
| Alcohols |
Lead |
| Anticholinergics |
Lithium |
| Arsenic |
Opioids |
| Beta Blockers |
PCP |
| Cholinergic Agents |
Phenothiazines |
| Carbon Monoxide |
Salycylates |
| Cyclic Antidepressants |
Sedative Hypnotics |
2. Pupils
| Miosis |
Mydriasis |
| Cholinergics |
Anticholinergics |
| Clonidine |
Glutethimide |
| Nicotine |
Meperidine |
| Phenothiazines |
Sympathomimetics
|
| PCP |
Withdrawal |
| |
|
3. Respiratory Effort
| Decreased |
Increased |
| Alcohols |
CO, CN |
| Barbiturates |
Drug induced metabolic acidosis |
| Benzodiazepine |
Drug induced hepatic failure |
| Opioids |
Drug induced methemoglobinemia |
|
Salycylates |
4. Heart Rate
| Tachycardia |
Bradycardia |
| Anticholinergics |
Alpha blockers |
| Antihistamines |
Beta blockers |
| Cyclic Antidepressants |
Calcium channel blockers |
| PCP |
Cardiac glycosides |
| Sympathomimetics |
Cholinergics |
(cocaine, amphetamine,
Clonidine theophylline) |
Cyanide |
| Withdrawal States |
Nicotine |
| |
Parasympathomimetics |
5. Blood Pressure
| Hypertension |
Hypotension |
| similar to tachycardia |
CO, CN |
| |
Cyclic Antidepressants |
| |
Iron |
| |
Opioids |
| |
Nitrites |
| |
Phenothiazines |
| |
Sedative-Hypnotics |
| |
Theophylline |
Note: Hypotension and Bradycardia can be caused by cardiac drugs (Beta-blockers,
Calcium Channel Blockers)
6. Temperature
| Hyperthermia |
 |
Hypothermia |
 |
| Anticholinergics |
Beta Blockers |
| MAOIs |
CO |
| Metals |
Cholinergics |
| PCP |
Ethanol |
| Phenothiazines |
Hypoglycemics |
| Salicylates |
Sedative-Hypnotics |
| Sympathomimetics |
|
| Withdrawal |
|
Toxidromes
1. Stimulant Toxidrome
-
Restlessness
-
Excessive speech and
-
Excessive motor activity
-
Tremor
-
Insomnia
-
Tachycardia
-
Hallucinations
2. Sedative Hypnotic
-
Sedation
-
Confusion
-
Delirium
-
Hallucinations
-
Coma
-
Paresthesias
-
Dysesthesias
-
Diplopia
-
Blurred vision
-
Slurred speech
-
Ataxia
-
Nystagmus
3. Opiate
-
Altered mental status
-
Miosis
-
Unresponsiveness
-
Shallow respirations
-
Slow respiratory rate
-
Bradycardia
-
Decreased bowel sounds
-
Hypothermia
4. Anticholinergic
-
Fever
-
Ileus
-
Flushing
-
Tachycardia
-
Urinary retention
-
Dry skin
-
Blurred vision
-
Mydriasis
-
Decreased bowel sounds
-
Myoclonus
-
Choreoathetosis
-
Psychosis
-
Hallucinations
-
Seizures
-
Coma
Anticholinergic
| Hot as a hare |
| Dry as a bone |
| Red as a beet |
| Mad as a hatter |
5. Cholinergic
-
Salivation
-
Lacrimation
-
Urination
-
Defecation
-
GI distress (diarrhea)
-
Emesis
-
Bronchorrhea, Bradycardia
Name the toxidrome 1
A two year old child presents to the Emergency department with frantic
parents because she is unarousable. The child has otherwise been well,
with no fever or other recent signs of infection.
PMH/PSH: Unremarkable
Physical Examination
-
A 2 year old infat arousable to deep pain stimulus
-
Pulse 120 RR 12 BP 100 (systolic)
-
HEENT: PERRL, Pupils 2 mm and reactive
-
Ht: RRR S1S2 normal
-
Lungs: Scattered ronchi
-
Abdomen: Decreased bowel sounds, soft, non-tender
-
Extremities: Atraumatic
-
Neuro: Lethargic as above
Name the toxidrome 2
A 31 year old female with a history of a seizure disorder presents after
an unknown ingestion. A family member states that she had slurred speech,
and was very drowsy before the arrival of paramedics.
Physical Examination
-
Temp 96 Pulse 104 RR 14 BP 90/60
-
HEENT: Pupils midrange and sluggish
-
Ht: RRR S1S2 nl
-
Lungs: Clear
-
Abdomen: Soft, non-tender
-
Skin: Blisters noted over antecubital fossa
-
Neuro: Lethargic woman, weak but present gag, symmetric sluggish reflexes
present
ANSWER?
Name the toxidrome 3
A 17 year old male with a history of behavioral problems at school presents
to the emergency department after a suicide attempt. He was noted to be
hallucinating earlier, and had a seizure prior to arrival.
PMH/PSH: Unremarkable
Physical Examination
-
A male who is arousable to loud verbal stimulus. He moves his extremities
spontaneously.
-
Pulse 120 RR 20 BP 125/80 T 100.5
-
HEENT: PERRL, pupils at 6 mm bilaterally
-
Ht: RRR S1S2 tachycardic
-
Lungs: Clear
-
Abdomen: Markedly decreased bowel sounds, fullness in the suprapubic area
-
Skin: Slighly flushed, dry
-
Neuro: 3+ reflexes globally
ANSWER?
Name the toxidrome 4
A 3 year old child is rushed into your ED by her parents who state that
she drank a white liquid from a mild bottle that was in the garage. The
child is lethargic, and appears to have marked respiratory distress. there
is an odor of garlic on her breath.
Physical Examination
-
P 140 RR 44 BP 80/60
-
HEENT: Pupils equal at 2 mm, excessive oral secretions noted
-
Ht: RRR S1S2 tachycardic
-
Lungs: Bilateral diffuse wheezes
-
Abdomen: Active bowel sounds, diffuse tenderness
-
Skin: Moist
Name the toxidrome 5
An 18 year old male took a handful of his sister's medication in attempt
to kill himself. He vomited three times at home, and had a generalized
tonic-clonic seizure. He now appears tremulous and anxious.
Physical Examination
-
Pulse 135 RR 22 BP 110/70
-
HEENT: PERRL, EOMI, Pupils at 6 mm
-
Ht: RRR S1S2 tachycardic
-
Lungs: clear
-
Abdomen: Hyperactive bowel sounds
-
Neuro: CN II-XII intact, hyper-reflexic
ANSWER?
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