9/23/19
§ None
Josh Radke, MD Director of Medical Toxicology Department of Emergency Medicine University of Iowa Hospitals and Clinics
§ A 56 yo male is found down. On arrival to scene, you find him next to multiple pill § Sympathomimetic bottles and some unmarked jugs of liquid that smell like alcohol.
§ Anti-cholinergic/Anti-muscarinic § Patient is mildly arousable
§ Cholinergic § WHAT DO YOU DO?????
§ Sedative hypnotic
§ Opioid
Mental To x id ro m e Tem p HR BP RR Status Pupils Skin GI
Sympatho- mimetic
Anticholinergic
Cholinergic
Opioids
Sedative/ hypnotics
1 9/23/19
www.nature.com
Mental To x id ro m e Tem p HR BP RR Status Pupils Skin GI
Sympathomimetic ↑ ↑ ↑ ↑ Agitated ↑ Sweaty ↓ /-
§ Alpha effects Anticholinergic § Severe HTN § ACS, dissection, ICH
Cholinergic § Beta Effects § dysrhythmias
Opioids § Other § Seizures § Severe hyperthermia Sedative/ hypnotics § Renal injury 2/2 rhabdo § Traum a
Did the patient overdose § Treat Possible Complications § Alpha effects on benzodiazepines? § Severe HTN § ACS, dissection, ICH § IVF
§ Beta Effects No § Active Cooling § dysrhythmias Yes
§ Benzodiazepines!!! § Other § Seizures Supportive care § Severe hyperthermia Give them benzo’s § Renal injury 2/2 rhabdo only § Traum a Supportive care
2 9/23/19
X www.cmaj.ca
Mental To x id ro m e Tem p HR BP RR Status Pupils Skin GI
Sympathomimetic ↑ ↑ ↑ ↑ Agitated ↑ Sweaty ↓ / -
Anticholinergic ↑ ↑ ↑ ↑ Delirious ↑ Dry ↓
Non-Reactive Opioids
Sedative/ hypnotics
“The peripheral nervous system.” users.rcn.com
Cholinergic
§ Physostigmine § Organophosphate pesticides § Physostigma venosum § Parathion, malathion, chlorpyrifos
§ Carbamate pesticides § Aldicarb, carbaryl, oxamyl
§ “Nerve agents” § Sarin, soman, tabun, VX gas
X § -stigmines X § Physostigmine, pyridostigmine, neostigmine
3 9/23/19
§ Cholinergic Toxidrome
§ Parasympathetic overdrive
§ DUMBBBELS
§ SLUDGE + Killer B’s X
§ Diarrhea § Salivation § M - Mydriasis
§ Urination § Lacrimation § Miosis § Urination § T – Tachycardi a § Bradycardia § Diarrhea
§ Bronchorrhea § GI distress § W – Weakness § Bradypnea § Emesis
§ Emesis § tH – Hypertension § Lacrimation § Bradycardia § Salivation § Bronchorrhea § F - Fasciculations
§ Bradypnea
Mental To x id ro m e Tem p HR BP RR Status Pupils Skin GI
Sympatho- mimetic
§ ABCs
Anticholinergic
CO = HR x SV § Atropine Cholinergic - ↓ ↓ / - ↓ Depressed ↓ ↑↑ ↑↑ § Muscarinic symptoms
V = RR x VT Opioids § Oxime Therapy § Pralidoxime (2-PAM ) OP § Nicotinic symptoms Sedative/ X hypnotics
4 9/23/19
Nerve Agents OP Pesticides § Opiates § Morphine § Codeine § Tabun – 14 hrs § Thebaine § Days to weeks § Semi-synthetic opioids § Sarin – 3 hrs § Hydrocodone § Hydromorphone Carbamate Pesticides § Oxycodone § Soman – 2-6 min § Heroin § Synthetic opioids § Fentanyl § Do not age § VX – 48 hrs § Methadone § Meperidine
Mental To x id ro m e Tem p HR BP RR Status Pupils Skin GI
Sympathomimetic
Anticholinergic
Cholinergic
Opioids ↓ ↓ Depressed - ↓ ↓ - ↓
Sedative/ hypnotics
5 9/23/19
Mental To x id ro m e Tem p HR BP RR Status Pupils Skin GI
Sympathomimetic
Anticholinergic
Cholinergic
Opioids ↓ ↓ Depressed - ↓ ↓ - ↓
Sedative/ ↓ ↓ - / ↓ Depressed ↓ / - hypnotics - - -
Mental To x id ro m e Tem p HR BP RR Status Pupils Skin GI
Sympathomimetic ↓ / - ↑ ↑ ↑ ↑ Agitated ↑ Sweaty
Anticholinergic ↑ ↑ ↑ ↑ Delirious ↑ Dry ↓ § [email protected]
Cholinergic - ↓ ↓ / - ↓ Depressed ↓ ↑↑ ↑↑
Opioids ↓ ↓ Depressed - ↓ ↓ - ↓
Sedative/ hypnotics - ↓ ↓ - / ↓ Depressed ↓ / - - -
6