Toxidromes

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Toxidromes

• Brad Peckler MD
• Lincoln Hospital Center
• Bronx, New York

2
Diagnostic Odors

• Cyanide
  Isopropanol
• Placidyl
  Hemlock
• Hydrogen sulfide Camphor
• Phosgene
  Naphthalene
• Ops/ Arsenic
  Hydrocarbons
• Methylsalicylate
• Chloral hydrate
• Zinc phosphate
• Paradichlorobenzene

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But as the world is harmoniously confusedWhere
order in variety we see,And where, though all
things differ, all agree.

• Alexander Pope

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• 69 y/o male with chronic low back pain presents
  with change in mental status.

5

• 28 y/o woman found in bathroom found unconscious
  with a syringe on the floor.

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Narcotics

• Hypoventilation
• Pinpoint pupils
• Somnolence
• Hypotension

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Narcotics

• Meperidine Vagolytic
• Serotonin syndrome
• Noromeperidine
• Propoxyphene Prolonged QT
• Mixed agonist/antagonist
• Synthetic opiates
• Drug combinations

8

• 18 y/o male brought in by NYPD because hes
  acting crazy and violent.
• HR 144 BP 180/90 RR 22
• Diaphoretic, 8mm pupils

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Sympathomimetics

• HTN
• Tachycardia
• Mydriasis
• Diaphoresis
• CNS excitement

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Sympathomimetics

• Drugs of abuse
• Adrenergic agonists
• Amphetamines
• Cocaine
• PCP
• TCA
• Early MAOI
• Sedative/hypnotic withdrawal

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• 70 y/o female used a flea bomb in her house and
  forgot to open the windows before entering the
  house
• C/o eye tearing, SOB, vomiting

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Cholinergic crisis

• Organophosphates
• Organophosphothionates
• Carbamates
• Insecticides
• Nerve agents
• 2-PAM

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Organophosphates

• Acetylcholinesterase
• Acetylcholine No hydrolysis
• Nervous tissue and RBC
• Concentrated in CNS
• Parasympathetic nerve endings
• Sympathetic nerve endings
• Somatic nerves
• Autonomic ganglia
• Pseudocholinesterase
• Liver and serum

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• Nicotinic
• CNS
• NMJ
• Adrenal
• Ganglia
• Sweating
• Tachycardia
• Hypertension

• Muscarinic
• Diarrhea
• Urination
• Meiosis
• Bronchospasm/secretions
• Emesis
• Lacrimination
• Salvation/sweating
• SLUDGE
• Bradycardia

15

• 18 y/o male BIBPD c/o hallucinations and cotton
  mouth
• OE temp 102, distended abdomen

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Visual Hallucinations

• Anticholinergics
• Sympathomimetics
• LSD
• PCP
• GHB
• Psilocybin
• Pentamidine
• Nutmeg/Mace

• Functional
• Organic
• Migraines
• Encephalitis
• Rabies
• Digoxin/Methanol
• Alcohol intoxication
• Alcohol withdrawal

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Hallucinations

• Olfactory
• Migrane, Pre-seizure, Acidosis, FB
• Frontal lobe tumor
• Sensory
• DTs, Cocaine, Menapause, HCG, Liver dz
• Auditory
• Functional, ASA, CN VIII

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• 25 y/o female took some pills
• Comatose, dry mucous membrane, tachycardic, had a
  seizure at home.

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Anticholinergics

• TCA
• Scopolamine/polo
• Neuroleptics
• Parkinson meds
• Benzotropine/trihexphendyl
• Jimson weed
• Antihistamines Methylqualone
• Piperdones Gyromitra

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TCA

• Anticholinesterase inhibitor
• Alpha blocker
• Sodium channel blocker (1A)
• Amine uptake inhibitor
• GABA inhibitor

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Anticholinergic vs Sympathomimetc

• Dry Wet
• Absent bowel sounds NL bowel sounds
• Psychosis Agitated
• Mydriasis Mydriasis
• Hyperthermia Hyperthermia
• Red Flushed
• Tachy/BP ? Tachy/HTN

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• 60 y/o prisoner with AMS and a suicide note. Had
  a seizure en route to hospital and has continued
  to seize for 45 minutes
• After ABCs
• FS 402
• 7.22/22/360

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Status Epilepticus

• INH
• Theophylline
• Hypoglycemia

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Seizure Hyperglycemia Metabolic Acidosis

• INH
• ASA
• DKA
• Theophylline
• CO/CN
• Anticholinergic
• Phenytoin