SYMPATHOMIMETIC TOXIDROME

Question 1

Approach to the Critical Sympathomimetic Toxidrome

Answer 1

Monitor
Oxygen
Vitals
IV Access
ECG / Airway Equipment

CIRCULATION
Autonomic excitation:
Midazolam 4-8 mg IV / IM q 5-10 min
Lorazepam 2-4 mg IV / IM q15 - 20 min

DISABILITY
SEVERE AGGITATION:

Midazolam 4-8 mg IV / IM q 5-10 min
Lorazepam 2-4 mg IV / IM q15 - 20 min
Haloperidol 5-10 mg IV / IM
Olanzapine 10 mg IM

SEIZURES:
Lorazepam (Ativan): 4 mg (0.01-0.03 mg / kg IV, max 0.1 mg / kg)
(Onset within 2 min, lasts 4-6 hrs)

Repeat up to 2 times

THEN
NO DILANTIN
Keppra
20 mg / kg (max 2 g) over 15 min
vs
40-60 mg / kg (2000-4000 mg) over 15 min

IV Propofol 1-2 mg / kg bolus THEN 1-10 mcg /kg / hr
OR
Midazolam 0.2 mg / kg IV bolus THEN up to 0.6 mg / kg / hr IV infusion

EXPOSURE

HYPERTHERMIA >39 C
Ice water submersion with NMB
OR
Cooling Blanket OR Ice Packs with lukewarm mist and fan

Question 2

Common sympathomimetics

Answer 2

Cocaine
Methamphetamine
Amphetamine (Adderall)
Lisdexamfetamine (Vyvanse)
MDMA
Cathiones (Bath Salts)

Question 3

DDx: Agitation

Answer 3

ICH / TBI

PCP, Anticholinergic, Serotonin Syndrome, Benzo / Opioid withdrawal,

CNS Infection

Hypoglycemia, Hypo/Hypernatremia, Hypoxemia, Hyperthermia

Nonconvulsive Status Epilepticus, Ischemic Stroke, PRES

Question 4

History & Physical

Answer 4

Tachycardic
Mydriasis

Hypertension
Hyperthermia
Diaphoresis
Aggitation

Hyperreflexia
Clonus
Choreiathetoid movement
Dystonic Reactions

Question 5

Investigations

Answer 5

Fingerstick glucose
Lytes
Ca / Phos / Mg
Cr
CK (rhabdo)
LFTs (Hyperthermic)
Troponin
Acetaminophen, Salicylates
Urine Tox (cocaine reliable within 72 hrs)
ECG
+/- CT Head

Question 6

General Management

Answer 6

AVOID BETA BLOCKERS

IV Fluids

Cooling: Chilled IV Fluids, cooling blanket, ice packs

Agitation, HTN, Tachycardia:
Lorazepam 2 mg IV titrated to efftect (0.1mg/kg in children)

Question 7

Complications

Answer 7

ACS
Aortic Dissection
Cardiomyopathy
Cardiotoxicity (sodium channel blockade) -> SVT, wide complex tachycardia

Pulmonary Edema
Pneumothorax

Intestinal ischemia / infarction
Fulminant Live Failure (hyperthermia, MDMA)

Seizures
CVA
Serotonin Syndrome

Question 8

Seizure Management

Answer 8

Lorazepam (Ativan): 4 mg (0.01-0.03 mg / kg IV, max 0.1 mg / kg)
(Onset within 2 min, lasts 4-6 hrs)

Repeat up to 2 times

THEN
NO DILANTIN
Keppra
20 mg / kg (max 2 g) over 15 min
vs
40-60 mg / kg (2000-4000 mg) over 15 min

IV Propofol 1-2 mg / kg bolus THEN 1-10 mg /kg / hr
OR
Midazolam 0.2 mg / kg IV bolus THEN up to 0.6 mg / kg / hr IV infusion

Question 9

Medications to Avoid

Answer 9

Fentanyl
Valproate
Ondansetron
Metoclopramide

Question 10

Arrythmias: SVT, wide complex tachycardia

Answer 10

SVT: Diltiazem 20 mg IV

Wide Complex Tachycardia: NaHC03 1-2 mEq/kg (1-2 amps)

Question 11

Benzo resistant HTN

Answer 11

Nitroprusside:
0.3 mcg/kg/min

Phentolamine: 2.5-5 mg IV