Toxicology 101

Joshua Rocker, MD

Schneider Children’s Hospital

Toxidromes

• 1. Anticholinergic

• 2. Sympathomimetic

• 3. Cholinergic

• 4. Opiod

• 5. Benzodiazepine

Anticholinergic

• Blind as a bat, hot as Hades, red as a beat, dry as a bone and mad as a hatter

• Skin- Dry and flushed skin, • BS- decreased BS• Eyes- dilated pupils • MS- agitated • Heart- tachy

Anticholinergic

• Rx: (block muscarinic receptor sites)– Antihistamines– TCAs– Antipsychotics– Skeletal muscle relaxants– Antiparkinson– Amantadine– Jimson weed/ Amanita

Sympathomimetic

• Similar to anticholinergic but diaphoretic, no urinary retention, hyperactive BS

Sympathomimetic

• Rx– Cocaine– Theophylline– Amphetamine– Caffeine– Decongestants

• Ephedrine, psuedoephedrine, phenylprpanolamine

Sympathomimetic

• Mechanism– Increase release of catechols (amphetamines)– Inhibit reuptake (cocaine)– Interfere with metabolism (MAOIs)– Direct stimulation of receptor (Epi)

Cholinergic

• Skin- WET • BS- increased BS• Eyes- pinpoint pupils • MS- Agitated• Heart- brady

• SLUDGE– Sialorrhea, lacrimation, urination, diaphoresis, gastric

emptying

Cholinergic

• BIG bad Bs– Bronchorrhea– Bradycardia– Bronchospasm

Cholinergic

• Muscarinic– Miosis

– Bradycardia

– Bronchorrhea

– Vomitting/diarrhea

– Sialorrhea

– Urinary incontinence

• Nicotinic– Mydriasis

– Tachycardia

– Bronchodilation

– HTN

– Diaphoresis

– Weakness

Cholinergic

• Rx

• Organophosphates (pesticides)

• Carbamates (physostigmine)

• Mushrooms

Opiod

• Skin-

• BS- decreased BS

• Eyes- pinpoint pupils

• MS- depression

• Heart- brady, hypotension

Opiod

• Morphine

• Codeine

• Hydromorphone

• Antidote- narcan

Benzodiazepine

• Skin-

• BS- decreased BS

• Eyes- pinpoint pupils

• MS- depression

• Heart- brady, hypotension

• Antidote- Flumazenil

Factoids

• Hyperthermia– Agitation/Seizures

• Sympatho, PCP, hallucinogens

– Inability to sweat• anticholinergics

– Increase muscle tone• Serotonin syndrome, Neuroleptic malignant syndr

– Uncouple oxidative phosphorylation• ASA

Hypothermia

• CNS depression– Sedative-hypnotics, EtOH, opiods

• Reduce total body glucose– Insulin, Oral hypoglycemics

Hypoglycemia

• HOBBIES

• Hypoglycemia• Oral hypoglycemics

– (not metformin-> Lactic acidosis)

• BB- Beta Blockers• Insulin• Ethanol• Salicylates

Hyperglycemia

• Stimulants (beta agonists, theophylline, caffeine, epi)

• CCB

• Thiazides

• Vacor

• Steroids

Miosis

• COPS

• Clonidine, Cholinergics

• Opiates, organophosphates

• Phenothiazine, phencyclidine

• Sedative hypnotics,

Mydriasis

• AAAS

• Antihistamines

• Antidepressants

• Anticholinergics

• Sympathomimetics

Anion gap with acidosis

• MUDPILES

• Methanol, Metformin• Uremia• DKA• Paraldehyde, phenformin• INH, iron, ibuprofen, inborn errors• Lactic acid• Ethanol, ethylene glycol• Salicylates

Osmolar Gap

• Calculated Osmolarity - Measured Osmolarity

• Calculated Osmolarity 2 [Na] + glucose/18 + BUN/2.8

Radiodense substances

• CHIPS

• Chloral hydrate

• Heavy metals

• Iron

• Phenothiazides

• Sustained-release (enteric coated) pills