Toxidromes & Recreational Drug Intoxication Cheatsheet

Vocabulary flashcards covering major toxidromes, recreational drug presentations, red flags, and frontline treatments from the EMS one-page reference.

Cholinergic Toxidrome

Poisoning pattern caused by organophosphates, carbamates, nerve agents, or other cholinesterase inhibitors; presents with SLUDGE/DUMBELS symptoms, bradycardia, bronchorrhea, miosis, and muscle weakness.

SLUDGE/DUMBELS

Mnemonic for cholinergic excess: Salivation, Lacrimation, Urination, Diarrhea, GI cramps, Emesis / Diarrhea, Urination, Miosis, Bronchorrhea, Bradycardia, Emesis, Lacrimation, Salivation.

"Wet and Weak" Pearl

Easy way to remember that cholinergic toxidrome features profuse secretions (wet) and neuromuscular weakness.

Atropine

First-line antidote for cholinergic poisoning; competitively blocks muscarinic receptors to dry secretions and improve heart rate.

Pralidoxime (2-PAM)

Oxime drug that reactivates acetylcholinesterase after organophosphate exposure; treats both muscarinic and nicotinic effects when given early.

Anticholinergic Toxidrome

Syndrome produced by antihistamines, TCAs, atropine, scopolamine, antipsychotics; features dry mouth, flushed skin, mydriasis, urinary retention, delirium, hyperthermia, tachycardia.

"Dry and Delirious" Pearl

Memory aid highlighting the hallmark dryness and mental status changes of anticholinergic toxidrome.

Dry as a bone, red as a beet, blind as a bat, hot as a hare, mad as a hatter

Classic phrase summarizing anticholinergic findings: anhidrosis, flushing, mydriasis/blurred vision, hyperthermia, and delirium.

Physostigmine

Reversible acetylcholinesterase inhibitor occasionally used for severe anticholinergic toxicity; requires cautious use due to risk of seizures or bradyarrhythmias.

Nicotinic Toxidrome

Neuromuscular presentation from organophosphates, nicotine, or insecticides; muscle fasciculations then flaccid paralysis, tachycardia, hypertension, sweating.

"Twitchy then Flaccid" Pearl

Mnemonic indicating nicotinic toxidrome’s progression from fasciculations to paralysis.

Miosis

Constricted pupils commonly seen in cholinergic poisoning and opioid overdose.

Mydriasis

Dilated pupils typical of anticholinergic, stimulant, or hallucinogen exposure.

Stimulant Intoxication

Cocaine, meth, MDMA, bath salts produce hyperthermia, tachycardia, hypertension, mydriasis, agitation, seizures, chest pain.

Treatment of Stimulant Toxicity

Large-dose benzodiazepines for agitation/seizures, active cooling, IV fluids; avoid beta-blockers.

MDMA (Ecstasy) Specific Risks

Can cause SIADH-related hyponatremia, serotonin syndrome, and rhabdomyolysis in addition to standard stimulant effects.

Cannabis Intoxication

Produces anxiety, tachycardia, nausea/vomiting, possible psychosis; managed with reassurance, quiet environment, and benzodiazepines if needed.

Alcohol/Benzodiazepine Overdose

Leads to sedation, ataxia, respiratory depression, hypotension; airway support, oxygen, glucose, and thiamine (if chronic drinker) required; naloxone ineffective.

Opioid Triad

Combination of miosis, respiratory depression, and decreased level of consciousness characteristic of opioid overdose.

Naloxone

Short-acting opioid antagonist used to reverse respiratory depression; may require repeat dosing and supportive ventilation.

Hallucinogen (LSD, Psilocybin) Toxicity

Visual hallucinations, paranoia, tachycardia; treat with calm environment and benzodiazepines as needed.

Ketamine/PCP Intoxication

Causes blank stare, nystagmus, aggression, hypertension, delirium; safety precautions and benzodiazepines are cornerstone of care.

Inhalant (Nitrous, Whippets) Toxicity

Produces dizziness, euphoria, headaches, arrhythmias, syncope; manage with high-flow oxygen, cardiac monitoring, supportive care.

Red Flag Transport Criteria

Indicators for immediate hospital transport: temperature > 104 °F, seizures, naloxone-unresponsive, RR < 10, severe agitation/psychosis, persistent vomiting, signs of trauma.

Quick Grab Treatment: Narcan

Keep readily available for suspected opioid intoxication with respiratory depression.

Quick Grab Treatment: Glucose/Dextrose

Administer to any altered patient or confirmed hypoglycemia to prevent neuro-glycopenic injury.

Quick Grab Treatment: Benzodiazepines

First-line control for agitation, stimulant toxicity, and seizures (can be given IM, IN, or IV).

Quick Grab Treatment: Fluids & Cooling

Essential for hyperthermia and rhabdomyolysis risk in MDMA or stimulant overdose.

Avoid Beta-Blockers in Stimulant Overdose

Non-selective beta-blockade can cause unopposed alpha-adrenergic stimulation leading to severe hypertension or coronary vasospasm.

Soft Restraints

Used to protect patient and providers during severe agitation or delirium until chemical sedation takes effect.