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Toxidromes.pptx
The document provides an overview of various toxidromes, categorizing toxic syndromes based on signs and symptoms, and outlines their clinical presentations and management strategies. Key toxidromes discussed include anticholinergic, cholinergic, opioid, sympathomimetic, hypno-sedative, serotonin syndrome, and neuroleptic malignant syndrome, highlighting both common causes and treatment protocols. The emphasis is placed on accurate diagnosis and effective management, utilizing patient history, physical examination, and appropriate laboratory tests.
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Toxidromes.pptx
- 1. TOXIDROMES DR KTD PRIYADARSHANI REGISTRARIN EMERGENCY MEDICINE TEACHING HOSPITAL- PERADENIYA 2023/04/17
- 2. Toxidromes • Toxic syndromes •Group drugs together according to the signs and symptoms they generally produce in patients • (so when encounter a patient presenting a certain way, easy to recognize the toxidrome) • Help to move toward final diagnosis
- 3. �What are themajor Toxidromes? � Anticholinergics � Cholinergic / Anticholinesterase � Sympathomimetics / Withdrawal � Opiate � Sedative/ hypnotic (Hypnosedative) � Serotonin syndrome/ neuroleptic malignant syndrome
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- 15. Anti-cholinergic toxidrome • AntagonizeAch receptors (muscarinic / nicotinic) • Major blockage – muscarinic • High doses – nicotinic at NMJ & autonomic ganglia
- 17. Anti-cholinergics Hot as aHare: warm skin Dry as a bone: dry skin and mouth Blind as a Bat: cycloplegia, mydriasis Red as a beet: flushed skin Mad as a Hatter: altered mental status, hallucinations
- 19. Anticholinergic • TCA, SSRI •Antihistamines • Carbamazepine • antipsychotics, • Antispasmodics • atropine
- 21. Management – • Resus-RSI-DEAD •Supportive • BDZ for agitation or seizures • Antidote – physostigmine (centrally acting reversible AChE inhibitor) • Avoid Rx agitation with Anticholinergics (haloperidol)
- 22.
- 23. Cholinergic toxidrome • IncreasedAch activity • Both central and peripheral • Both nicotinic and muscarinic
- 24. Anticholinesterases ❖ Organophosphate & carbamate insecticides ❖Nerve gas (sarin) Cholinergic (Cholinomymetics) ❖ Nicotine ❖ Mushrooms ❖ Pilocarpine
- 27. DUMBELS • Diaphoresis, Diarrhea, Decreasedblood pressure • Urination • Miosis • Bronchorrhea, Bronchospasm, Bradycardia • Emesis, Excitation of skeletal muscles • Lacrimation (tearing) • Salivation, Seizures SLUDGE • Salivation • Lacrimation • Urination • Defecation • GI Stress • Emesis
- 28. Management - • Resus-RSI-DEAD •Decontamination • Atropine – until dry secretions • Pralidoxime
- 29.
- 30. Opioid toxidrome • Dueto narcotics & narcotic derivatives • Bind to opioid receptors in CNS & bowel � Classic presentation � CNS depression � Respiratory depression � Miosis
- 31. Commonly used opioids �Heroin, � Morphine, � Hydromorphone, � Codeine, � Hydrocodone, � Oxycodone, � Fentanyl
- 34. Treatment - � RSI-DEAD � Naloxone � Competitive opioid antagonist (mu, kappa & delta) � Bolus 400 mcg IV/IM � Rpt 100mcg every 30-60 seconds until spontaneous respiration � 2/3 of initial dose per hour infusion if patient not conscious
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- 36. Sympathomimetic toxidrome • Acton sympathetic nervous system • Direct or indirect effect on catecholamines • Direct act – alpha agonists, dopaminergic agents • Indirect – increase catecholamine release, inhibit breakdown/delay reuptake (amphetamines, cocaine)
- 37. Clinical Features • Tachycardia •Hypertension • Hyperthermia • Hyperreflexia • Mydriasis • Diaphoresis • Normal bowel sounds • Tremors • Chest pain • Rhabdomyolysis
- 39. Treatment • Supportive • IVFluids • CVS (HT/Tachycardia) • BDZ • phentolamine • Vasodilator infusion (GTN) • No β blockers • Seizures/Agitation • BDZ • Cooling- Dantrolene
- 40.
- 41. Hypno-sedative toxidrome ❖Modulate activityof GABA neurotransmitter complex ❖ Include in ❖ Benzodiazepines ❖ Barbiturates ❖ Zolpidem, zopliclone ❖ Baclofen ❖ Gamma-hydroxybutyrate ❖ Chloral hydrate ❖ paraldehyde
- 43. Clinical Features • CNSdepression • sedation, confusion, amnesia • Respiratory depression • CVS depression • Nystagmus • Ataxia/ loss of coordination • Loss of bladder control
- 45. Treatment �Largely supportive �Extreme cautionwith antidotes �Flumazenil can reverse benzodiazepines, but can also cause intractable seizures and so is not used routinely.
- 46. Contraindications to Flumazenil � Overdoseof unknown agents. � Suspected or known physical dependence on benzodiazepines. � Suspected cyclic antidepressant overdose. � Co-ingestion of seizure-inducing agents. � Known seizure disorder � Suspected increased intracranial pressure.
- 47.
- 48. Serotonin syndrome � MAOI:phenelzine, tranylcypromine, isocarboxazid, pargyline, rasagiline, and selegiline � SSRI: fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, and escitalopram � SNRI: venlafaxine, desvenlafaxine, levomilnacipran, and duloxetine � TCA: amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, protriptyline, and trimipramine � Miscellaneous: trazodone (moderate potency), bupropion (low potency),tramadol , Lithium, meperidine
- 51. Severity Pattern Category Clinicalfeatures Mild Mild agitation, mild fever (<40°C), tremor, myoclonus, hyperreflexia, diaphoresis, mydriasis, elevated blood pressure and heart rate Moderate Marked agitation, hyperthermia (>40°C), myoclonus, hyperreflexia, ocular clonus, increased bowel sounds Severe Hyperthermia (>41.1°C), delirium, marked muscle rigidity, marked swings in blood pressure and heart rate
- 52. Treatment � Stop allserotonergic therapy � Initiate cardiopulmonary monitoring, establish peripheral IV access, and obtain ECG � IV fluid rehydration � External cooling measures for hyperthermia � Benzodiazepines for agitation � Use short-acting IV antihypertensives (nitroprusside or esmolol) for severe hypertension � Use direct-acting IV vasopressors (norepinephrine, epinephrine, or phenylephrine) for hypotension resistant to IV fluid resuscitation � Consider cyproheptadine for moderate to severe clinical features refractory to supportive care.
- 53. Neuroleptic Malignant Syndrome � Anidiosyncratic drug reaction to antipsychotics � Occurs with in 3-9 days of starting drug � Due to central dopaminergic blockade
- 54. Clinical Features ▪ Majorcriteria – ▪ fever, muscle rigidity, psychomotor slowing and altered mental status, sympathetic nervous system liability, recent dopaminergic antagonist exposure or dopamine agonist withdrawal ▪ Minor criteria- ▪ Increased CK levels or myoglobinuria, tachycardia, tachypnea, hypersalivation, tremor, muscle cramps ▪ Exclude ▪ No other infection, toxic, metabolic or neurologic cause identified ▪ both major and at least 5 minor criteria must be present
- 55. Treatment � Supportive. � Withdrawany potentiating drugs � Exclude DD � Airway and breathing difficulties � nondepolarizing agents (e.g., rocuronium) are preferred over depolarizing agents (e.g., succinylcholine).
- 56. � Temperature � externalcooling measures; � pharmacologic antipyretics are not beneficial � Sedation - to decrease agitation and sympathetic activity; a benzodiazepine, such as lorazepam. � Hypertension- GTN or Nitroprusside � Antidote-Dantrolene and Bromocriptine in severe cases.
- 57.
- 58. Tackling Toxidromes • Goodhistory • Directed physical examination • Vital signs,Pupils,Skin, bowel bladder • Simple tests • Rapid glucose, ECG, ABG, SE, RFT etc • Simple interventions
- 62. References � Tintinali EM9Edition � Life in the fast lane � FRCEM Intermediate- text books
- 63.