Toxidromes

Question 1

Toxidrome

Cholinergic Pathophysiology:

Answer 1

Acetylcholinesterase inhibition → excess acetylcholine
parasympathetic (muscarinic) → SLUDGE (salivation, lacrimation, urination, defecation, GI upset, emesis) and bradycardia Sympathetic (nicotinic) → tachycardia, arrhythmias, hypertension, mydriasis
Skeletal muscle (nicotinic) → fasciculations, weakness, respiratory muscle paralysis
Brain→ delirium, seizures, confusion

Question 2

Toxidrome

DUMBBELLS / cholinergic toxidrome:

Answer 2

Diarrhea, Diaphoresis
Urination
Miosis
Bradycardia, Bronchospasm Emesis
Lacrimation, Low BP Salivation

Question 3

Toxidromes

Cholinergic ASAP:

Answer 3

ABCs, IV, O2, monitor, VS, EKG

Question 4

Toxidromes

Cholinergic Tx and Labs:

Answer 4

Hx/Exam: h/o exposure to organophosphates, insecticides, physostigmine, pilocarpine, nerve agents, SAMPLE hx
Labs: may do labs but dx based on hx/exam

Question 5

Toxidromes

Cholinergic Treatment:

Answer 5

Tx: Atropine 2-4 mg IV (or 4-6 mg IM), peds dose 0.02mg/kg IV, both q 5-10 min PRN til dry secretions. May need large doses!- muscarinic symptoms
Pralidoxime (2-PAM) 1-2 gm IV, may repeat in 1 hr, then q 12 hr (peds dose is 25 mg/kg IV/IM)- nicotinic symptoms
If pt develops ↑BP d/t 2-PAM…Phentolamine 0.1mg/kg IV
Pathophys: Organophosphates irreversibly bind and inhibit cholinesterases at muscarinic and nicotinic receptors. Carbamates bind reversibly and are less toxic. Both cause too much ACh at nerve endings.
2-PAM cleaves agent from cholinesterase enzyme.

Question 6

Toxidromes

Opioid Toxidrome Signs and Symptoms:

Answer 6

Miosis, altered mental status, respiratory depression, pulmonary edema, decreased bowel sounds

Question 7

Toxidromes

Opioid Toxidrome ASAP:

Answer 7

ABCs, IV, O2, monitor, VS, EKG

Question 8

Toxidromes

Opioid Toxidrome Hx:

Answer 8

Hx: drug taken, timing, accidental vs SI vs recreational, IVDU, SAMPLE hx

Question 9

Toxidromes

Opioid Toxidrome Exam:

Answer 9

Exam: Drowsy, ↓RR, ↓BP, apnea, miosis, ↓bowel sounds, track marks, sz

Question 10

Toxidromes

Opioid Toxidrome Labs:

Answer 10

Labs: CBC, BUN/Cr, lytes, gluc, ASA, APAP, UDS

Question 11

Toxidromes

Anticholinergic Toxidrome Causes:

Answer 11

Antihistamines, jimsonweed, atropine, TCA, antiparkinsonian agents, certain antipsychotics, skeletal muscle relaxants, mushrooms

Question 12

Toxidromes

Anticholinergic Toxidrome ASAP:

Answer 12

ASAP: ABCs, IV, O2, monitor, VS, EKG

Question 13

Toxidromes

Anticholinergic Toxidrome Hx/Exam:

Answer 13

Hx/Exam: SAMPLE hx
Red as a beet (flushed), Dry as a bone (dry, ↓secretions), Hot as a hare (↑temp, ↑BP, ↑HR), Blind as a bat (mydriasis, cycloplegia), Mad as a hatter (delirium, AMS) (Just like sympathomimetics except DRY!- urinary retention and lack of diaphoresis)

Question 14

Toxidromes

Anticholinergic Toxidrome Labs:

Answer 14

Labs: CBC, BUN/Cr, lytes, gluc, LFTs, CK/MB/Trop, ASA, APAP, UA, UDS, urine pH, hCG

Question 15

Toxidromes

Anticholinergic Toxidrome Treatment:

Answer 15

Tx: supportive, Benzos, physostigmine 0.5-2 mg q 10-30 min (blocks degradation of ACh- not in TCA, risk of arrest), sodium bicarb (for wide complex tachycardia- TCA)

Question 16

Toxidromes

Sedative/hypnotic ASAP:

Answer 16

ASAP: ABCs, IV, O2, monitor, VS, EKG

Question 17

Toxidromes

Sedative/hypnotic Hx/Exam:

Answer 17

Hx/Exam: drowsiness, slurred speech, nystagmus, hypotension, ataxia, coma, respiratory depression, ataxia

Question 18

Toxidromes

Sedative/hypnotic Labs:

Answer 18

Labs: clinically driven, perhaps ASA, APAP, UDS among others

Question 19

Toxidromes

Sedative/hypnotic Tx:

Answer 19

Tx: supportive care, flumazenil not indicated unless iatrogenic OD benzo, relatively well-tolerated, but danger increases if combined with ETOH, opioids, or TCAs