Toxidromes
Toxidromes may be useful, but can be misleading since overdoses can be from multiple substances and may present with a mixed picture - Dr. Dan Rusyniak
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A Basic, Practical Approach to Toxicology
Common toxidromes include sympathomimetic, anti-cholinergic, sedative-hypnotic, and opioid. They can be thought of as 2 larger classes, the ‘fast and furious’ and ‘downers’.
In patients with apparent ‘fast and furious’ toxidromes, it is important to consider the alternate diagnoses of neuroleptic malignant syndrome and serotonin syndrome. Typical and atypical antipsychotics can cause neuroleptic malignant syndrome, which is characterised by increased temperature, diaphoresis, and muscle rigidity. Serotonin syndrome, which causes similar symptoms, can be caused by a variety of substances, including selective serotonin reuptake inhibitors and MDMA.
Resources
Toxidromes; what’s your poison?
Although the concepts of toxidromes allow us to quickly and accurately figure out the majority of our overdosed/poisoned patients, it is by no means an all encompassing concept. There are many common overdoses that do not fit neatly into one of the mentioned toxidromes. There are constantly new designer drugs hitting the streets and people find new, innovative ways of abusing old drugs.
An Algorithm for the Evaluation of Toxidromes
Whole-bowel irrigation Indicated for sustained-release formulations, expulsion of body packing materials, or ingestion of agent not absorbed by activated charcoal.
Drug Overdose in the Emergency Department
Toxidromes Anticholinergic Cholinergic Opioid Sympathomimetic Serotonin syndrome Sympatholytic Sedative-hypnotic
Seven Toxidromes Well Summarized...
This post is my personal minicourse on toxidromes.
The Role of Sodium Bicarbonate in the Management of Some Toxic Ingestions
Based on the available literature and empiric experience, the IV administration of sodium bicarbonate appears to be beneficial in the management of certain pharmacological toxicities such as sodium channel blockers poisonings, salicylate intoxication, and ingestion of methanol and ethylene glycol. However, most of the data originates from case reports, case series, and expert consensus recommendations.
The “Big 5” Toxidromes
Step 1: Evaluate the Airway. General principles. “If they can’t speak, they can’t control their airway”. “If GCS is <8, intubate”. In the real world, it’s a clinical judgement call.
Toxicological diagnosis in the critical patient: The challenge
Some toxidromes have similar characteristics and are not fully presented as described in the literature, which can be confusing when making the diagnosis, so it must be carefully evaluated and inquired with the patient or companions.
Toxidromes
Determining the toxidrome is a practical and useful approach in managing poisoned patients.
Toxidromes: Common Poisoning Syndromes to Know
To help with identification, toxins can be grouped based on common presenting physical findings. These groupings are known as “toxidromes.” Recognizing common toxidromes will assist your assessment and treatment of the exposed patients, even when the specific toxin is unknown. Prompt recognition not only leads to better patient outcomes, but also can potentially limit a toxic exposure of the responding emergency responders. While it is beyond the scope of this article to present every toxidrome, there are six that EMS providers can readily identify and treat.
A Basic, Practical Approach to Toxicology
Common toxidromes include sympathomimetic, anti-cholinergic, sedative-hypnotic, and opioid. They can be thought of as 2 larger classes, the ‘fast and furious’ and ‘downers’:
Sedative Toxidrome
Consider flumazenil in pediatric ingestion or if benzodiazepines were administered for procedural sedation. flumazenil: titrated doses until reversal of respiratory depression -> may require an infusion. dose: 0.2mg IV -> 0.1-0.4mg/hr
Anticholinergic intoxication
???? Dilated pupils. ???? Delirium. ???? Tachycardia. ???? Dry skin – This is an essential element, which helps separate anticholinergic toxidromes from sympathomimetic toxidromes.
The Gasman Handbook
The toxidrome concept can be useful because of the varying effects that result when a combination of drugs is taken - the prevailing toxidrome often being the most important to manage. However, the clinical picture can still be very complicated in mixed ingestion, limiting this applicability and requiring individual clinical assessment.
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