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.