PDA Lecture 27: Toxicology: Toxidromes lecture 2

Normal vital signs chart (review)

Basic Guide of the Poisoned Patient (review)

Common Mental Status in Overdose Patients: Agitation

A state of heightened psychomotor activity, restlessness, and emotional tension

Common causes: Sympathomimetics, anticholinergics, withdrawal syndromes

Common Mental Status in Overdose Patients: Delirium

An acute, fluctuating disturbance in attention, awareness, and cognition. Often includes confusion and hallucinations

Common causes: Anticholinergics, sedative-hypnotic withdrawal, organophosphates, severe infections

Common Mental Status in Overdose Patients: Psychosis

A loss of contact with reality, often involving hallucinations, delusions, or disorganized thinking

Common causes: Hallucinogens (LSD, PCP), amphetamines, synthetic cannabinoids, anticholinergics

Common Mental Status in Overdose Patients: Euphoria

Intense feelings of pleasure, well-being, or excitement

Common causes: Opioids, stimulants, some hallucinogens

Common Mental Status in Overdose Patients: Somnolence

Drowsiness or sleepiness; patient is easily arousable but may fall asleep without stimulation

Common causes: Opioids, benzodiazepines, barbiturates, sedatives

Common Mental Status in Overdose Patients: Stupor

A state of unresponsiveness from which the patient can only be aroused with vigorous or painful stimulation

Common causes: High-dose sedatives, opioids, ethanol, barbiturates

Common Mental Status in Overdose Patients: Coma

A deep state of unconsciousness in which the patient cannot be aroused by any external stimulus

Common causes: Severe opioid overdose, large sedative/hypnotic ingestion, hypoglycemia, or hypoxia

Common Mental Status in Overdose Patients: Confusion

A lack of clarity in thinking, disorientation, or inability to concentrate

Common causes: Anticholinergics, sedatives, hypoglycemia, serotonin syndrome

Toxidromes describe the groups of signs and symptoms that consistently result from a group of toxins or drugs

describe the groups of signs and symptoms that consistently result from a group of toxins or drugs

Toxidrome examples (7_

- CNS-mental status

- Ophthalmic system (pupil size)

- GI system (peristalsis)

- Skin (dry skin vs diaphoresis)

- Mucous membranes (well-hydrated vs dry)

- Genitourinary system (urinary retention vs incontinence)

- Vital signs

Peristalsis

The involuntary constriction and relaxation of the muscles of the intestine

Diaphoresis

excessive sweating due to a secondary condition

Toxidromes are a constellation of f signs and symptoms associated with exposure to a specific class or group of toxins or drugs including... (5)

- Anticholinergic

- Cholinergic

- Opioids

- Serotonin toxicity

- Sympathomimetics

How sympathomimetics affect vital signs, mental status, etc.:

BP:

Pulse:

Respirations:

Temperature:

Mental Status:

Pupil size:

Peristalsis:

Diaphoresis

Other:

BP: increased

Pulse: increased

Respirations: increased

Temperature: increased

Mental Status: agitated

Pupil size: increased

Peristalsis: may not change or may increase

Diaphoresis: Increased

Other: tremor, seizures, diaphoresis

Chief complaint of sympathomimetics

altered mental status and euphoria

Sympathomimetic case:

History of Present Illness: Joy, a 25-year-old female, is brought to the emergency department. In the last 4 hours, her behavior has become increasingly hyperactive, and she is now expressing extreme joy and euphoria.

Vital Signs: Temperature: 37.8°C (100.0°F), Heart Rate: 160 bpm, Blood Pressure: 140/85 mmHg

Physical Examination:

• General:

• Neurologic:

• Cardiovascular:

• Respiratory:

• GI:

• General: Euphoric, talkative, hyperactive

• Neurologic: Dilated pupils, increased deep tendon reflexes

• Cardiovascular: Tachycardia, slightly increased blood pressure

• Respiratory: Slightly increased respiratory rate, no signs of distress

• Gastrointestinal: No obvious abnormalities

Hyperreflexia

the presence of hyperactive stretch reflexes of the muscles

How serotonin toxicity affects vital signs, mental status, etc.:

BP:

Pulse:

Respirations:

Temperature:

Mental Status:

Pupil size:

Peristalsis:

Diaphoresis

Other:

BP: increased

Pulse: increased

Respirations: may not change or increase

Temperature: may not change or increase

Mental Status: normal to agitated delirium

Pupil size: may not change or increase

Peristalsis: increased

Diaphoresis: increased

Other: Clonus, tremor***, seizures

Chief complaint of serotonin toxicity

Agitation and Tremors

Serotonin toxicity case:

History of Present Illness: Fear, a 22-year-old male, is brought to the ED by his friends after he began exhibiting bizarre behavior and intense anxiety at a music festival.

Vital Signs: Temperature: 38.9°C (102.0°F), Heart Rate: 130 bpm, Blood Pressure: 150/85 mmHg, Respiratory Rate: 24/min

Physical Examination:

General:

• Neurologic:

• Cardiovascular:

• Respiratory:

• General: Agitated, trembling***, and anxious

• Neurologic: Dilated pupils, hyperreflexia, myoclonus

• Cardiovascular: Tachycardia, slightly increased blood pressure

• Respiratory: Increased respiratory rate, no signs of respiratory distress

Myoclonus

sudden brief involuntary twitching or jerking of a muscle or group muscles

How anticholinergics affect vital signs, mental status, etc.:

BP:

Pulse:

Respirations:

Temperature:

Mental Status:

Pupil size:

Peristalsis:

Diaphoresis

Other:

BP: may not change or increase

Pulse: increased

Respirations: variable

Temperature: increased

Mental Status: delirium

Pupil size: increased

Peristalsis: decreased

Diaphoresis: decreased

Other: Dry mucous membranes****, flush, urinary retention

Chief complaint of anticholinergics

agitation and confusion

Anticholinergic case:

History of Present Illness: Anger, a 30-year-old male, is brought to the ED due to sudden onset of agitation and confusion. He was behaving aggressively at home, exhibiting bizarre and hostile actions.

Vital Signs: Temperature: 38.3°C (100.9°F), Heart Rate: 110 bpm, Blood Pressure: 140/90 mmHg, Respiratory Rate: 18/min

Physical Examination:

• General:

• Neurologic:

• Cardiovascular:

• Respiratory:

• General: Agitated, combative, and confused

• Neurologic: Dilated pupils, dry oral mucosa, decreased bowel sounds

• Cardiovascular: Tachycardia, slightly increased blood pressure

• Respiratory: Normal respiratory rate, no signs of respiratory distress

Anticholinergic toxidrome acronyms

How cholinergics affect vital signs, mental status, etc.:

BP:

Pulse:

Respirations:

Temperature:

Mental Status:

Pupil size:

Peristalsis:

Diaphoresis

Other:

BP: variable

Pulse: variable

Respirations: variable

Temperature: change unlikely

Mental Status: normal to depressed- more hypoactive

Pupil size: variable

Peristalsis: increased****

Diaphoresis: increased****

Other: Salivation***, lacrimation***, urination***, diarrhea, bronchorrhea, fasciculations, paralysis

- vital signs not greatly changed, increse in water

Chief complaint of cholinergics

Nausea and vomiting

Bronchorrhea-

Fasciculations-

Bronchorrhea- production of voluminous water sputum

Fasciculations- involuntary rapid muscle twitches (weak)

Cholinergic case:

History of Present Illness: Disgust a 21-year-old female, is brought to the ED by his coworkers after she suddenly developed severe nausea, vomiting, and abdominal cramps at a work event.

Vital Signs: Temperature: 37.2°C (99.0°F), Heart Rate: 90 bpm, Blood Pressure: 120/80 mmHg, Respiratory Rate: 18/min

Physical Examination:

• General:

• Neurologic:

• Cardiovascular:

• GI:

• General: Pale, diaphoretic, and visibly distressed.

• Neurologic: Confused, salivating excessively.

• Cardiovascular: Normal heart rate, normal blood pressure.

• Gastrointestinal: Active vomiting, abdominal cramps, increased bowel sounds

How opioids affect vital signs, mental status, etc.:

BP:

Pulse:

Respirations:

Temperature:

Mental Status:

Pupil size:

Peristalsis:

Diaphoresis

Other:

BP: decreased

Pulse: decreased

Respirations: decreased

Temperature: decreased

Mental Status: depressed

Pupil size: decreased

Peristalsis: decreased**

Diaphoresis: change unlikely

Other: Hyporeflexia

Chief complaint of opioids

altered mental status and depressed breathing

Opioid case:

History of Present Illness: Sadness, a 28-year-old female, is brought to the ED by her roommate who found her unresponsive and breathing slowly in their apartment.

Vital Signs: Temperature: 37.0°C (98.6°F), Heart Rate: 60 bpm, Blood Pressure: 110/70 mmHg, Respiratory Rate: 8/min, Oxygen Saturation: 91% on room air

Physical Examination:

• General:

• Neurologic:

• Cardiovascular:

• Respiratory:

• General: Unresponsive, lethargic, and breathing at a slow rate

• Neurologic: Pinpoint pupils, decreased level of consciousness

• Cardiovascular: Bradycardia, hypotension

• Respiratory: Shallow respirations, occasional sighing

Diaphoresis can be present in the following toxidromes...

A. Anticholinergic

B. Sympathomimetic

C. Serotonin toxicity

D. All of the above

E. B and C

E. B and C

What signs and symptoms would you expect to find in a patient with an anticholinergic toxidrome?

A. Miosis

B. Tachycardia

C. Dry skin

D. Salivation

E. Delirium

B. Tachycardia

C. Dry skin

E. Delirium

A 43-year-old man was brought to the ED, after being found on the ground next to a vegetable patch. He has white powder on his face and clothing. During the physical exam he began vomiting

- Vital signs: T: 35.7°C, HR: 53 bpm, R: 25 rpm, BP: 110/55 mm Hg, SPO2: 85%

- He exhibits gurgling respirations with pooled secretions in oropharynx

- Pupils 2mm

- Skin cool and diaphoretic

Which toxidrome is this patient experiencing?

A. Anticholinergic

B. Cholinergic

C. Sympathomimetic

D. Opioid

B. Cholinergic

A 21-year-old-woman was found unresponsive in her dorm by her roommate. Empty pill bottles standing next to her bed.

- Vital signs: T: 36.7 °C, HR: 72 bpm, RR: 4 rpm, BP: 110/60 mm Hg, SPO2: 81%

- Pupils 1mm

- Skin cyanotic but dry

Which toxidrome is this patient experiencing?

A. Anticholinergic

B. Cholinergic

C. Sympathomimetic

D. Opioid

D. Opioid

A 35-year-old man with depression was found altered at home by his spouse. Over-the-counter-pill bottles were found in the trash. Patient is alert but agitated and combative

- Vital signs: T: 38.6 °C, HR: 127 bpm, RR: 23, BP: 156/98, SPO2: 99%

- Pupils: 8mm

- Skin flushed and dry

- Dry mucous membranes

Which toxidrome is this patient experiencing?

A. Anticholinergic

B. Cholinergic

C. Sympathomimetic

D. Serotonin Toxicity

A. Anticholinergic

Summary chart of the toxidromes and their effects

Sympathomimetics physiology

• SNS stimulation by increasing circulating levels of catecholamines (epinephrine, norepinephrine, and dopamine)

• Adrenergic receptors, specifically activation of beta-adrenergic receptors

Sympathomimetic drugs (4)

• Amphetamines

• Bath Salts

• Cocaine

• Ketamine

Clinical features of sympathomimetics (7)

• Hyperthermia

• Tachycardia

• Hypertension

• Agitation / Psychosis

• Seizures

• Dilated Pupils (but will react to light)

• Diaphoresis, secondary to hyperthermia

Antidote for sympathomimetics

Manage signs and symptoms

Physiology of serotonin drugs/toxicity

• Associated with increased serotonergic activity in both the peripheral (PNS) and central nervous systems (CNS)

• 5-HT receptor activation

Serotonin drugs (6)

• Monoamine oxidase inhibitors

• Selective serotonin reuptake inhibitors

• Tramadol

• MDMA

• Amphetamines

• Lamotrigine

Serotonin drugs are usually precipitated by the simultaneous initiation of _______________________, can also occur after the initiation of a _____________ serotonergic drug in a susceptible individual

- 2 or mor serotonergic drugs

- single

Clinical features of serotonin drugs (5)

• Tremor, Myoclonus, Hyperreflexia, Trismus, Rigidity

• Diaphoretic

• Hypertension, hyperthermia, tachycardia, tachypnea

• Mydriasis

• Confusion, agitation, coma

Antidote of serotonin drugs

Cyproheptadine

Physiology of anticholinergic drugs/toxicity

Inhibition of muscarinic cholinergic neurotransmission (blocking acetylcholine from binding receptors) gives these drugs their effect

Anticholinergic drugs

• Antihistamines

• Sleep aids

• tricyclic antidepressants

• cold preparations

• atroping

Plants: deadly nightshade (belladona, killed R & J), jimson weed

Clinical features of anticholinergic toxicity (6)

• "Red as beet' - vasodilation

• "Dry as a bone" - inhibition of sweat glands

• "Hot as a hare" - lack of sweating and increased stimulation cause hyperthermia

• "Blind as a bat" - blurry vision due to inability to constrict pupil and accommodate.

• "Mad as hatter" - central muscarinic blockade causing delirium, hallucinations, psychosis, seizures. Picking at skin common.

• "Full as a flask" - urinary retention due to detrusor muscle and urethral sphincter inability to relax

Antidote to anticholinergic toxicity

physostigmine

What is used as an antidote for a tricyclic antidepressant overdose?

sodium bicarbonate

Physiology of cholinergic drugs/toxicity

• Inhibition of acetylcholinesterase (AChE) causes increased levels of acetylcholine.

• Muscarinic acetylcholine receptors

Cholinergic drugs (2)

• Pesticides resulting in field workers exposed (dermal, inhalation) to sprayed chemicals.

• Organophosphates

Clinical features of cholinergic toxicity: SLUDGE & the Killer B's (main cause of deaths in cholinergic) (muscarinic effect)

• Salivation

• Lacrimation (crying-key feature)

• Urination

• Defecation (diarrhea)

• GI cramping (distress)

• Emesis

• Bronchorrhea

• Bronchospasm

• Bradycardia

• Pinpoint pupils (nicotinic)

• Muscle weakness / fasciculations. (nicotinic)

• Paralysis (nicotinic)

• CNS depression / Coma / Seizure (nicotinic)

Antidote to cholinergic toxicity

atropine

T/F: Cholinergic toxicity is the LEAST common toxidrome

TRUE

Physiology of opioids/opioid overdose

Stimulation of three receptors provides CNS depression and analgesia: mu (MOP), kappa (KOP) and sigma (DOP)

Opioid drugs

Natural opiate derivatives:

Synthetic:

• Natural opiate derivatives: codeine, heroin, hydrocodone, morphine, oxycodone

• Synthetic: buprenorphine, dextromethorphan, fentanyl, methadone, meperidine

Clinical features of opioid overdose (6)

• Bradypnea (key finding)

• Bradycardia

• Hypotension

• CNS depression, coma

• Pinpoint pupils

• Bowel obstruction

Antidote to opioid overdose

Naloxone

Which of the following toxidromes is caused by an overdose of APAP?

A. Opioid

B. Serotonin toxicity & sympathomimetic

C. Cholinergic

D. None of the above

D. None of the above

- anticholinergic