ppt on a topic of emergency medicine which is very essential called poisoning of toxidromes

1. ED Management on
“Toxidromes” poisoning
By Shama Rani Paul
Year 4
MAHSA University

2. Definition and Types
 group drugs together according to the signs and symptoms they generally produce in
patients (so when you encounter a patient presenting a certain way, you will be able to
recognize the toxidrome)
 What are the major toxidromes?
 Anticholinergics
 Sympathomimetics / Withdrawal
 Opiate / Sedative
 Cholinergic / Anticholinesterase

3. 1. Anticholinergics
 interfere with the binding of acetylcholine to muscarinic receptors
 Hyperthermia
 Dilated pupils (mydriasis)
 Dry skin
 Vasodilation causing flushed skin
 Agitation / Hallucinations
 Tachycardia and possibly dysrhythmias
Tricylic antidepressants, antihistaminics, tegretol(carbamazepine),
antipschyotics, antispasmodics, jimson seed, atropine

5. Treatment for overdose
 Pre-hospital - focus on safe, rapid transport with oxygen administration and cardiac
monitoring, and staying alert for complications such as vomiting, seizures or violent
behaviour
 In-hospital - supportive measures in most cases. A rarely used option is the
administration of physostigmine, a short-acting cholinesterase inhibitor

6. 2. Sympathomimetrics
 mimics the sympathetic nervous system effects
 Alcohol and drug withdrawal present the same way as sympathomimetics, which is why
they are grouped together
 Tachycardia, Dysrhythmias
 Hypertension
 Diaphoresis
 Goosebumps
 Delusions, Paranoia,
 Seizures
 Increased temperature
 Dilated pupils
Caffeine, cocaine, amphetamine, theophylline, ecstasy

7. Treatment for ovedose
 Pre-hospital - same as that for an anticholinergic overdose
 In-hospital - administration of a benzodiazepine to calm agitated patients.

8. 3. Opioids
o Pin-point pupils (Miosis)
o Respiratory depression – Due to decreased sensitivity of the respiratory center to CO2 (slow as
2-4 breaths/min)
o Sedation – Often GCS 3
o Nausea and vomiting – Due to stimulation of the chemoreceptor trigger zone
Hypothermia Heroin, Morphine, Hydromorphone, Codeine, Porpoxyphene, Hydrocodone,
Oxycodone, Fentanyl, Meperidine
Always consider an opiate overdose when assessing elderly patients with altered LOC who have
been prescribed an opiate for pain control - Increasing pain or confusion can cause accidental
overdoses

9. Treatment for overdose
 Pre-hospital - focus on supporting the ABC’s. Often significantly require suctioning, placement of
an airway adjunct and supported ventilations with a BVM. Even if the patient can be roused,
monitor the respiratory effort carefully. Sometimes patients need to be told to ‘take a few deep
breaths’ to maintain adequate ventilations
 sedation exhibited by opiate overdose patients are often due to a combined effect of the drug
itself, as well as high carbon dioxide levels
 In-hospital - administration of Naloxone . Always use with caution - you can very quickly go from
having an easily managed and sedate patient, to a combative individual in full withdrawal
 Combine heroin with amphetamine or cocaine, “speed balling”

10. 4. Cholinergics
 elevated levels of acetylcholine, either through direct ‘cholinergic’ effects or by inhibiting the enzyme
responsible for the breakdown of acetylcholine (cholinesterase)
 DUMBELS
 Diaphoresis, Diarrhea, Decreased blood pressure
 Urination
 Miosis
 Bronchorrhea, Bronchospasm, Bradycardia
 Emesis, Excitation of skeletal muscles
 Lacrimation (tearing)
 Salivation, Seizures
Cholinergic: Nicotine, Mushrooms
Anticholinesterases: Organophosphate insecticides, Nerve gas (sarin)
o SLUDGE
o Salivation
o Lacrimation
o Urination
o Defecation
o GI Stress
o Emesis

11. Treatment for overdose
 pre-hospital - focuses on the ABC’s and vigorous monitoring. Be prepared for seizures
 ALS and in-hospital - administration of Atropine, an anticholinergic.

12. Diagnosis of poisoning
 Ask patient or relatives/friends what drugs or poison have been taken (not always accurate)
 Self-poisoning –
 under the influence of alcohol
 may not know which tablets he/she took
 check any bottles or packets for the names and quantities of drugs/poisons that were available
 unconscious or severely poisoned, look in hospital notes for details of previous overdosesed.
 Record the time of ingestion of the drug or poison
 Examine the patient all over for signs of poisoning, injection marks or self-injury
 mimicking poisoning (eg head injury, meningitis)
 traditional Chinese medicines or herbs can cause signifcant toxicity

13. Toxidromes: features suggesting a particular
poison
o Coma with dilated pupils, divergent squint, tachycardia, increase muscle tone, increase reflexes
and extensor plantars  tricyclic antidepressant or orphenadrine poisoning
o Coma with hypotension, respiratory depression and decrease muscle tone  barbiturates,
clomethiazole, benzodiazepines with alcohol, or severe tricyclic antidepressant poisoning
o Coma with slow respiration and pinpoint pupils is typical of opioid poisoning
o Tinnitus, deafness, hyperventilation, sweating, nausea and tachycardia are typical of salicylate
poisoning
o Agitation, tremor, dilated pupils, tachycardia  amphetamines, ecstasy, cocaine,
sympathomimetics, tricyclic antidepressants, or selective serotonin re-uptake inhibitors

14. Assessment and Monitoring
• Assess and record conscious level, Observe frequently.
• Check blood glucose in patients with confusion, coma or fiits.
• Monitor breathing and record respiratory rate. Use a pulse oximeter, but note that SpO 2 may be
misleadingly high in carbon monoxide (CO)poisoning
• Check ABG if patient is deeply unconscious or breathing abnormally.
• Record and monitor the ECG if a patient is unconscious, has tachy- or bradycardia or has taken
drugs or poisons with risk of arrhythmias.
• Record BP and temperature.

15. Investigations
 most useful : paracetamol and salicylate levels, blood glucose, ABG, and urea & electrolytes
(U&E)
 Measure paracetamol if there is any possibility of paracetamol poisoning (this includes all
unconscious patients). Record the time of the sample on the bottle, and in the notes.
 Many labs can measure salicylate, iron and lithium and also check for paraquat if necessary.
 Comprehensive drug screening is rarely neededand is only available in specialist centres

16. References
 https://www.lakeridgehealth.on.ca
/en/ourservices/resources/Toxidr
omes%20Self%20Study%20Packa
ge.pdf
 Oxford Hanbook of Emergency
Medicine