Opioid toxidrome Sedative-hypnotic toxidrome Sedative-hypnotic toxidrome Salicylate toxidrome

1. The PCC, Toxidromes,
and “Deadly in a Dose”
Peds Ingestions
John Dayton, MD FACEP
Emergency Physician, Assistant Professor
Board Member, Utah ACEP
Legislative Committee Member, UMA

2. Disclosure
Most of these slides are mine, but I also
included information from the Poison Control
Center’s (PCC) 2012 review book and a
toxidrome presentation.
I did this for two reasons: the data goes with
their Toxidrome booklets I’m handing out and
their data is really good.

3. Goals
• Discuss scope of poisonings in Utah
• Discuss common toxidromes and common
prescriptions, OTCs and supplements from
each category
• Discuss initial evaluation and stabilization
• Discuss use of PCC resources and EMS
resources
• Quiz time (with prizes)

4. Utah Poisonings from 2012 Report

5. Utah Poisonings from 2012 Report

6. Utah Poisonings from 2012 Report

7. Utah Poisonings from 2012 Report

8. Utah Poisonings from 2012 Report
Why?
•Kids – 99% accidental
•Teens – 42% accidental
•Adults – 61% accidental
Where?
•Own home – 88%
•Other home – 5%
•Work – 2%
•Other – 5%

9. Utah Poisonings from 2012 Report
•Unintentional – 84%
•Intentional – 11%
•Adverse Reaction – 2.5%
•Other (tampering,
poisoning, etc) – 1%
•Unknown – 0.6%

10. Utah Poisonings from 2012 Report
Call outcome:
• 76% of calls handled over the phone
• 90% of Peds cases managed over the phone
• 20% required treatment in health care facility

11. Utah Poisonings from 2012 Report

12. Most Common Substances
Less than 6
years
6-19 years 20+ Years
Cosmetics/
personal care
Analgesics Analgesics
Analgesics Cough and Cold Sedative/hypnotic
Cleaning
substances
Sedative/hypnotic Antidepressants
Vitamins &
Minerals
Antidepressants Bites/envenomations
Topicals Foreign bodies Cleaning substances
Utah 2008

13. “Deadly in a Dose”
Beta-blockers
Calcium channel blockers
Clonidine
Opioids (narcotics)
Oral hypoglycemics
Toxic alcohols
Tricyclic antidepressants
“olols”: carvedilol (coreg), labetalol, metoprolol
(toprol),timolol (timoptic eye drop)
“pines”: amlodipine (norvasc), nifedipine (procardia),
nicardipine (cardene), verapamil, diltiazem (cardizem)
Clonidine (kapvay or nexiclon) for HTND or ADHD
Lortab, percocet, tylenol 3, fentanyl, oxcodone,
oxycontin, hydrocodone, methadone, suboxone
Sulfonylurea (glyburide, blipizide), acarbose, glucovance
(glyburide/metformin)
Methanol (wood alcohol  blindness and death),
isopropyl alcohol (solvent), ethylene glycol (antifreeze)
Amitriptyline (elavil), imipramine (tofranil)

14. “Deadly in a Dose”
Ingestions are possibly deadly for Ped patients in
homes where any family members (especially
grandparents) are taking meds for:
• Hypertension – beta Ca blockers (-olos)
• Diabetes – sulfonylureas (glipizide)
• Pain - narcotics
• Parkinsons – selegiline (MAO-B inhibitor),
benztropine (cogentin – anticholinergic/antihistamine)
• Psychiatric problems – TCAs (elavil, Imipramine)

15. Poisoning Fatalities
• Sedative/Hypnotics/Antipsychotics
– benzodiazepines (Valium, Xanax, Klonipin)
– antipsychotics (Seroquel)
• Opioids (Oxycontin, methadone)
• Antidepressants (amitriptyline, Prozac)
• Cardiovascular drugs (beta blockers, calcium channel
blockers, clonidine)
• Acetaminophen alone and combinations (pain and
cold meds)
• Alcohols
• Stimulants and street drugs

16. Toxidrome
• A constellation of signs and symptoms that
characterize a particular toxin or a category of
toxins
• Helps in “unknown” situations to narrow
down possible toxins
• Vital signs and toxicology assessment essential
to identify possible toxidromes

17. Toxidrome Card - example

18. Toxicology Assessment
• Signs and Symptoms
– vital signs (HR, BP, R, Temp)
– neurologic status
– pupils
– skin color/temp
• Allergies
• Medications in home
• Past medical history
• Circumstances Leading to Event

19. Toxidrome #1
• A 16-year-old girl found by parents to be
confused, agitated and actively hallucinating
(picking bugs off skin)
• Vital signs: HR 124 bpm, BP 135/88 mm Hg, T
100.8°F
• Pupils: 5 mm bilaterally (mydriasis)
• Skin: flushed, dry skin
• Physical exam: dry mouth, diminished bowel
sounds

20. Anticholinergic Toxidrome
• Blind as a bat
• Dry as a bone
• Red as a beet
• Hot as a hare
• Mad as a hatter
Exam: mydriasis, dry
flushed skin,
hyperthermia, altered
mental status, seizure,
tachycardia,
hypotension, urinary
retention
Antidote: Physostigmine
Other Treatment: fluids

21. Anticholinergics
OTC: antihistamine (benadryl)
Prescriptions:
• TCAs (amatriptyline/elavil, imipramine)
• Antipsychotics (chorpromazine,
fluphenazine/prolixin, haldol)
• Parkinson meds (benztropine)
• Muscle relaxants
• Scopolamine
• Atropine
Natural: Jimson weed, deadly nightshade

22. Toxidrome Case #2
• 32-year-old woman found delirious and very
agitated; extremely paranoid; appears to be
hallucinating
• Vital signs: HR 130 bpm; BP 170/100 mm Hg;
R 16/min; T 100.4°F
• Pupils 7mm (mydriasis)
• Skin: moist, diaphoretic

23. Stimulant (Sympathomimetic)
Toxidrome
Vitals: elevated BP, HR and hyperthermia
HEENT: mydriasis
Derm: diaphoresis
Cardiac: tachycardia, SVT, Afib, Aflutter, heart
blocks, chest pain
Neuro: seizures, stroke
Psych: psychosis, delirium,
bruxism (teeth grinding)

24. Stimulants
OTC: decongestants (pseudoephedrine),
phenylephrine
Prescription: Adderall, Ritalin, Thyroid
Supplements (synthroid)
Natural: ma huang
Illegal: PCP, cocaine, meth
• Treatment: Benzodiazepines

25. Toxidrome Case #3
 A 15-year-old boy found unresponsive,
snoring in bed.
 Vital signs: HR 50 bpm, BP 90/60 mm Hg, RR
5/min, Temp 97°F
 Pupils 1-2 mm (miosis)
 Neurologic: unresponsive to painful stimuli
 Physical exam: decreased bowel sounds

26. Opioids (“Narcotics”)
Signs and Symptoms
• CNS and respiratory
depression
• Miosis
• Hypotension,
bradycardia,
hypothermia
Antidote
• Naloxone 0.4-2 mg
Examples: heroin, morphine, oxycodone, fentanyl,
hydrocodone, hydromorphone, buprenorphine (Suboxone),
methadone

27. Toxidrome Case #4
• A 45-year-old female found unresponsive at
home. She was last seen approximately 20 hours
prior. She does not respond to painful stimuli.
• Vital signs: HR 60 bpm, BP 100/50 mm Hg, T 96°F,
RR 10/min
• HEENT: 4 mm bilaterally, reactive to light
• Skin: pressure sores
• Physical exam: poor gag reflex,
decreased muscle tone
and depressed reflexes

28. Sedative-Hypnotic Agents
• Central nervous system depression
– ataxia, slurred speech, drowsiness, confusion → coma
– loss of reflexes, respiratory depression, myocardial
depression
• Barbiturates like phenobarbitol, pentobarbital
(nembutal)
• Benzodiazepines like chordiazepoxide (librium),
diazepam (valium), alprazolam (xanax)
• Combo drugs: fioricet/fiorinal (contains
butalbital), donnatol
• Alcohol and narcotics
• Additive/synergistic effects in combination

29. Sedative-Hypnotic Agents:
Alcohol Derivatives
Methanol:
• Found in windshield wiper fluid, anifreeze, solid fuels (sterno)
• Conversion to formic acid  anion gap acidosis - intoxicated, headache, CNS
depression, visual change “looking through snow field”  blindess,
tachycardia/ypnea, abd pain, N/V
• Hallmark: blind drunk with anion gap metabolic acidosis
Ethylene glycol
• Found in coolants (antifreeze)
• oxalic acid  renal toxicity
• Sx include intoxication, HA, CNS depression,
N/V, Acute Renal Failure
• Oxalate crystals in urine can be seen with woods lamps
Isopropyl alcohol
• Found in rubbing alcohol and hand sanitizers
• CNS depression, coma, N/V, hemorrhagic gastritis
• Hallmark: drunk without +serum alcohol

30. Toxidrome #5
• A 14-year-old girl found acting strangely with
complaints of nausea and vomiting and ringing in
ears
• Vital signs: HR 110 bpm; BP 120/60 mm Hg; R
30/min; T 100.2°F
• Pupils 4 mm
• Skin: diaphoretic

31. Salicylates
Exam
• Neuro: confusion, agitation, seizures, lethargy  coma
• Vitals: increased respiratory rate, HR and temp
• Skin: normal to sweaty
• GI: nausea and vomiting
• Hallmarks: tinnitis (ringing ears) or other hearing
changes
OTCs, prescriptions – aspirin, shampoos, pepto-bismol,
oil of wintergreen, muscle rubs
Treatment – supportive care +/- intubation, charcoal, HD

32. Toxidrome #6
• A 56-year-old woman with confusion, shortness of
breath, vomiting and diarrhea
• Vital signs: HR 50 bpm; BP 90/palp mm Hg; R 32/min;
T 98.6°F
• Pupils 2 mm
• Skin: profuse sweating, tearing and rhinorrhea
• Physical exam: hyperactive bowel sounds, muscle
fasciculations

33. Cholinergic Toxidrome
Mnemonics:
• DUMBELLS:
• Diarrhea
• Urination
• Miosis, muscle fasciculations & weakness
• Bronchorrhea, Bradycardia, Bronchospasm
• Emesis
• Lacrimation, Loss of muscle strength
• Salivation, Sweating
• SLUDGE: Salivation/sweating, Lacrimation, Urination,
Defecation, GI distress, Emesis
• Killer Bs: Bradycardia/Bronchorhea/Bronchospasm)

34. Cholinergic Meds
Medications: Alzehimers meds
(donepizil), Myasthenia Gravis
meds (pyridostimine,
edrophonium), Carbamates like
soma, felbatol for seizures
Chemicals: organophosphates
(farming), carbamates
insecticides, sarin, cytocybe and
inocybe mushrooms

35. Cholinergic Treatment
Treatment:
• atropine and 2PAM (Pralidoxime)
• supportive care
• benzos

36. Other Drugs to be Aware of
Tylenol – 140 mg/kg can kill the liver. Presents in 4
stages. RUQ pain with elevated LFTs and bili.
Antidote is NAC.
SSRIs - fluoxetine (prozac), citalpram (celexa),
paroxetine (paxil) can cause N/V, abd pain,
tachycardia, CNS sedation, hyperthemia,
diaphoresis, AMS, nystagmus, myoclonus, hyper-
relfexia. Give supportive care, benzos for sz,
cyproheptadine is the antidote for seratonin
syndrome.

37. Other Drugs to be Aware of
• MAOIs – Depression meds like phenlzine (nardil),
trancylcypromaine (parnate), MAO blockers for
Parkinsons (selegiline, rasagiline), and St John’s Wart.
Will inhibit monoamine oxidase  decreased
inactivation of biogenic amines like epineph, norepi,
seratonin  excess catecholamines 
sympathomimetic reaction. Treat with benzos and
antipyretics for agitation/rigidity/sz
• Isoniazid (INH) – Tuberculosis med causes lupus-like
syndrome, reduces Vitamin B6 and can lead to
seizures. Treatment is supportive, pyridoxine (Vit B6).

38. Drugs of Abuse
Drug Symptoms/Toxidrome Treatment
Cocaine Sympathomimetic Supportive, benzos
Amphetamines (extacy,
ADD and narcolepsy meds,
weight loss supplements)
sympathomimetic Supportive, benzos
Opiates Opiate Nalaxone, support
respiration
PCP Sympathomimetic, rotary
or vertical nystagmus,
hyperthermia
Supportive, benzos,
cooling, sedation as
needed
GHB (used as date rape
drug, ravers, body builders)
Coma with episodes of
agitation, hypothermia,
sudden awakening
supportive

39. Poison Control Centers
• Available 24-hours/day
• Specialists in poison information
• pharmacists and nurses
• extensive toxicology knowledge and resources
• Medical toxicologist available 24/7
• Outreach education materials

40. Role of the PCC
They take history of exposure
They make assessment based on history, circumstances, health
status
They recommend treatment
They recommend management site
• manage on site
• refer to Health Care Facility
• private vehicle
• EMS
They follow up on exposures
Communication bridge during disasters
• PCC has 800 mHz radio

41. Tox Management
Emergency stabilization
• Airway, Breathing, Circulation
“Coma cocktail”
• Naloxone (0.01 mg/kg)
• Amp D50
• some include thiamine (100 mg IV before D50)
Activated charcoal
• best if used within 1-2 hours of ingestion
• Do not use if you have concern for aspiration
• Does not work for metals, alcohols, hydrocarbons and
caustics

42. Tox Management: ABC’s
Airway: check for flaccid tongue, gag reflex, clear
secretions, nasal trumpet/oral airway, position to
avoid aspiration
Breathing: check sats and RR – give Os, give
albuterol for brochospasm, atropine for
bronchorrhea, BVM and intubate as needed to
protect airway (low sats, AMS, caustic burn)
Circulation: IV access, draw labs, fluids for
hypotension, EKG monitoring (bicarb for long QT)

43. Antidotes

44. Dialysis and Charcoal

45. EKG abnormalities by Drugs
Bradycardia – beta and calcium
blockers, digitalis, clonidine
Tachycardia – anticholinergics,
stimulants
QRS widening –TCAs,
sympathomimetics
Ischemic changes – stimualnts
(cocaine)
Digoxin – Salvidor Dali mustache
From Rapid Interpretation of EKG's copyright © 2013 COVER Publishing Co. Inc.

46. Quiz Time
What toxidrome will these cause?
• Percocet
• Jack Daniels
• Soma (hint – has barbiturate)
• Pepto-Bismol
• PCP
• Crystal Meth
• Organophosphate fertilizer
• Jimson Weed

47. Quiz Time
You pick up a lethargic child who was staying with
his grandma who has diabetes. What medication
do you worry about?
You pick up some ravers from SaltAir who have
pacifiers in their mouth? What drug and
toxidrome are you concerned about?
You are called to the home a depressed teenager
who just broke up with her boyfriend. She has
ringing in her ear. What med did she OD on what
toxidrome does she have?

48. Quiz Time
You are called to an orchard where some
workers are foaming at the mouth and having
difficulty breathing. What was their likely
exposure and what toxidrome do you see?
How do you treat it?
You pick up a patient who admits a soma
overdose. What kind of symptoms do you
expect to see and what will his tox screen look
like?

49. Picture Sources
Peds Ingestion – www.emsworld.com
Xanax pill - psychiatrist-blog.blogspot.com
PCP hallucination – www.defense.gov
Mydriasis - webeye.ophth.uiowa.edu
Mad Hatter - http://www.alice-in-wonderland.net/pictures/mad-hatter-pictures.html
Jimson Weed – www.commons.wikimedia.org , sowandhoe.blogspot.com
Peter Pan Hallucination - theosophical.wordpress.com
Ecstasy Pacifier - www.michaelallenblair.com
Ma Huang – www.eagleherbs.com
Miosis – www.tumblr.com/tagged/miosis
Naloxone - http://www.tumblr.com/tagged/naloxone
Pressure Sore - www.snjourney.com
Sterno – www.zenstoves.net
Pesticides – animalpetdoctor.homestead.com
Sarin gas newspaper - www.sciencemuseum.org.uk
Atropine and 2PAM - www.atsdr.cdc.gov
Antidote, Activated Charcoal, and Hemodialysis Charts – www.ebmedicine.net
Dali Mustache - From Rapid Interpretation of EKG's copyright © 2013 COVER Publishing Co. Inc