As a continuity of my presentation on overview of treatment of poison and overdose, this presentation discusses 4 toxidromes and 2 overdose states.

2. Resuscitation Risk Assessment Supportive Care
and Monitoring
InvestigationsDecontamination
Enhanced
Elimination Antidotes Disposition

3. Syndrome caused by a dangerous level of toxins
in the body.

4. Symptoms:
Killer B's: Bradycardia,
Bronchorrhea and Bronchospasm
SLUDGE: Salivation, Lacrimation,
Urination, Diarrhoea, &
Gastrointestinal (Emesis)
DUMBBELLSS: Diarrhoea,
Urination, Miosis, Bradycardia,
Bronchospasm, Emesis,
Lacrimation, Lethargy, Salivation
and Seizures
Common Substances:
Carbamates
Mushrooms
Organophosphates
 Complications:
 Rapid onset of respiratory
failure
 Seizures
 Dehydration
 Neurological sequelae

5. Resuscitation
• ABCDE
• Objective Signs of
Cholinergic Crisis:
Atropine
Risk Assessment
• Agent(s), Dose(s),
Time since ingestion
• Clinical features
and progress
• Patient factors and
co-morbidities
Supportive Care
• Well ventilated
Room
• Universal
Precautions
• Intravenous Fluids
• Catheterization
Investigations
• Screening:
Cholinesterase
levels
• Specific: ECG, Chest
X-ray, Electrolytes,
renal function, ABG
Decontamination
• Should never be at
higher priority than
resuscitation
• Activated Charcoal
Elimination Antidotes
• Atropine
• Pralidoxime (Only
for
organophosphates)

6. Symptoms:
 Agitated Delirium
 Signs Of Peripheral Muscarinic
Blockade: Blurred Vision,
Coma, Decreased Bowel
Sounds, Delirium, Dry Skin,
Fever, Flushing,
Hallucinations, Ileus, Memory
Loss, Mydriasis (Dilated
Pupils), Myoclonus, Psychosis,
Seizures, & Urinary Retention
 Substances:
 The four "anti"s: Antihistamines,
Antipsychotics, Antidepressants,
and Antiparkinsonian drugs
 Atropine, Benztropine, Datura,
and Scopolamine.
“Blind as a bat, mad as a hatter, red as a beet, hot as Hares, dry as a bone, the bowel and
bladder lose their tone, and the heart runs alone.”
 Complications:
 Hypertension, Hyperthermia,
and Tachycardia

7. Resuscitation
• ABCDE
Risk Assessment
• Agent(s), Dose(s),
Time since
ingestion
• Clinical features
and progress
• Patient factors and
co-morbidities
Supportive Care
• Quiet, Well lit Room
• Intravenous Fluids
• Catheterization
• Diazepam for agitation
• Avoid Anticholinergic
agents
Investigations
• Screening: ECG
• Specific: Drug
levels, Electrolytes,
renal function, ABG
Decontamination
• Activated Charcoal
Elimination Antidotes
• Physostigmine (to
confirm the
diagnosis; if
adequate sedation
not achieved)

8.  Symptoms:
 Anxiety, Delusions, Diaphoresis, Hyperreflexia, Mydriasis, Paranoia,
Piloerection, And Seizures, Hyperactive Bowel Sounds, Sweating
 Seen within 2hrs post ingestion; life threatening complications seen within
6hrs post ingestion
 Complications:
 Hypertension & Tachycardia
 Substances Involved:
 Salbutamol, Cocaine, Amphetamines, Ephedrine (Ma Huang),
Methamphetamine, Phenylpropanolamine (PPA's), & Pseudoephedrine

9. Resuscitation
• ABCDE
• Diazepam for
seizure, agitation
Risk Assessment
• Agent(s), Dose(s),
Time since ingestion
• Clinical features and
progress
• Patient factors and co-
morbidities
Supportive Care
• Well ventilated Room
• Intravenous Fluids
• Catheterization
• Diazepam for agitation
• Ambient cooling
Investigations
• Screening: ECG (MI)
• Specific: Drug
levels, Electrolytes,
renal function,
ABG, CT Scan
Decontamination
• Activated Charcoal
• Whole bowel
irrigation
• Laparotomy
Elimination Antidotes
• No Antidotes

10.  Symptoms:
 Vasodilation, reflex tachycardia,
hypotension +/- evidence of poor
perfusion
 CCBs and BBs: CVS: bradycardia,
hypotension, AV block, heart
failure; CNS: lethargy, confusion,
seizures, coma (generally
secondary to the CVS effects)
 Digoxin: increased automaticity
(e.g. PVCs, PACs and other
dysrhythmias)
Agents:
 α1 blockers, β blockers, α2
agonists, calcium channel
blockers

11. Resuscitation
• ABCDE
Risk Assessment
• Agent(s), Dose(s),
Time since ingestion
• Clinical features and
progress
• Patient factors and
co-morbidities
Supportive Care
• Intravenous Fluids
• Catheterization
• Vasopressors
• Calcium
• Glucagon
Investigations
• Screening: ECG
(MI)
• Specific: Drug
levels,
Electrolytes, renal
function, ABG, CT
Scan
Decontamination
• Activated Charcoal
• Whole bowel
irrigation
• Lapratomy
Elimination Antidotes
• No Antidotes

12. Symptoms:
 Intense craving, dysphoria, autonomic hyperactivity and
gastrointestinal distress.
 Anxiety, restlessness and dysphoria; Insomnia; Intense craving;
Yawning; Lacrimation; Salivation; Rhinorrhoea; Anorexia, nausea
and vomiting; Abdominal cramps and diarrhoea; Mydriasis;
Piloerection; Diaphoresis; Flushing; Myalgia and arthralgia;
Hypertension and tachycardia in severe cases.
 Altered mental status, delirium, hyperthermia and seizures: LOOK
FOR COMPLICATIONS/ DIFFERENTIALS

13. Early Management:
 Safe cessation or dose reduction
 Management of symptoms and medical complications
 Retention of patient in treatment program
Pharmacologic Treatment:
 Opioid Replacement Therapy: Methadone 20-40mg/day, then
tapered; Buprenorphine 4-16mg/day
 Antagonist Detoxification: Rapid detoxification (naltrexone,
buprenorphine and clonidine under close clinical supervision; Ultra
Rapid: not recommended

15. Toxic Dose:
 single ingestion >250 mg/kg or >12 g over a 24-hour period
 >350 mg/kg: severe liver toxicity unless appropriately treated
Clinical features of overdose
 Nausea, vomiting, malaise, Right upper quadrant pain
 Liver enlargement and tenderness, Jaundice, confusion (hepatic
encephalopathy), bleeding diathesis
 Marked elevated LFTs, elevation in hepatic enzymes,
hyperammonemia, hypoglycemia, lactic acidosis
 Sequale: renal failure, death

16.  Resuscitation
 Risk assessment
 Supportive Care
 Investigation: Serum Paracetamol levels
(only after 4hrs of ingestion)
 Decontamination: Activated Charcoal
(1g/kg)
 Elimination: Exchange Transfusions;
Arteriovenous Hemofiltration,
Hemodialysis, Hemoperfusion
 Antidote: N-acetylcysteine; 150mg/Kg
over 15 min; 50mg/Kg over next 4 hrs;
100mg/Kg over next 16 hrs up to 36hrs
 Liver transplantation

17. We conclude General Pharmacology.
Next Class will be on Sunday, 27th December, 2015 (Poush
12, 2072)
Topic: Autonomic Nervous System (Introduction and
Cholinergic Drugs)