Toxidrome recognition

What it is

A toxidrome is a group of signs and symptoms associated with exposure to a particular substance or class of substances. The named ones are the sympathomimetic, the anticholinergic or antimuscarinic, the cholinergic, the opioid, and the ethanol or sedative-hypnotic toxidrome, with serotonin syndrome and neuroleptic malignant syndrome added as two more.

How it presents

The cholinergic toxidrome comes from ACh receptor agonists such as pilocarpine, or from AChEIs such as organophosphates. DUMBELS holds it: Diarrhea and Diaphoresis, Urination, Miosis, Bradycardia and bronchorrhea, Emesis, Lacrimation, Salivation. On the patient that is pin point pupils, sweating, crying, a running nose, frothing at the mouth from salivation and bronchorrhea, vomiting, bradycardia, urination and diarrhea.

The anticholinergic toxidrome comes from low potency antipsychotics, oxybutynin, ACh receptor antagonists such as Ipratropium, Atropine and Scopolamine, TCA and antihistamines. Its picture is hot as a desert for the hyperthermia, blind as a bat for the dilated pupils of mydriasis, mad as a hatter for the confusion, dry as a bone for the dry mouth and urinary retention, red as a beet for the flushed skin. With those go tachycardia, absent bowel sounds, shaking, and grabbing at invisible objects.

The sympathomimetic toxidrome comes from Epinephrine, Cocaine, Amphetamine (Aderol) and Methylphenidate (Ritalin). MATHS holds it: Mydriasis, Agitation, Tachycardia, Hypertension and Hyperthermia, Sweating. Tachypnea, diaphoresis and increased bowel sounds go with it.

The sedative-hypnotic toxidrome comes from BZN and barbiturates, and shows ataxia, nystagmus and slurred speech with nonspecific pupils. A young man brought in unwell and unsteady, disoriented with a GCS of 6/15, a rate of 7 breaths per minute and an oxygen saturation of 91% on room air while his BP is 110/55 mm Hg, his HR 82 per minute and his temperature 37.4 C, is the picture of respiratory depression with CNS depression, and the two names to hold there are narcotics and sedative-hypnotics.

Serotonin syndrome follows ingestion of 2 or more drugs such as MAOIs and SSRIs, or 5HT2A or 5HT1A serotonin receptor agonists such as citalopram, ecstasy, tramadol and lithium. HARMED holds it: Hyperthermia; Agitation and ANS instability; Rigidity and Reflexes increased; Myoclonus and Mydriasis; Encephalopathy; Diaphoresis and Diarrhea. Neuroleptic malignant syndrome is FARMER: Fever, Autonomic changes, Rigidity, Mental status changes, Elevated enzymes (CK), Reduced reflexes. Mental status changes such as agitation, delirium, confusion and, to a lesser extent, obtundation can develop from hyperthermia.