Toxicology 101 Joshua Rocker, MD Schneider Children’s Hospital

Toxidromes 1. Anticholinergic 2. Sympathomimetic 3. Cholinergic 4. Opiod 5. Benzodiazepine

Anticholinergic Blind as a bat, hot as Hades, red as a beat, dry as a bone and mad as a hatter Skin- Dry and flushed skin, BS- decreased BS Eyes- dilated pupils MS- agitated Heart- tachy

Anticholinergic Rx: (block muscarinic receptor sites) –Antihistamines –TCAs –Antipsychotics –Skeletal muscle relaxants –Antiparkinson –Amantadine –Jimson weed/ Amanita

Sympathomimetic Similar to anticholinergic but diaphoretic, no urinary retention, hyperactive BS

Sympathomimetic Rx –Cocaine –Theophylline –Amphetamine –Caffeine –Decongestants Ephedrine, psuedoephedrine, phenylprpanolamine

Sympathomimetic Mechanism –Increase release of catechols (amphetamines) –Inhibit reuptake (cocaine) –Interfere with metabolism (MAOIs) –Direct stimulation of receptor (Epi)

Cholinergic Skin- WET BS- increased BS Eyes- pinpoint pupils MS- Agitated Heart- brady SLUDGE –Sialorrhea, lacrimation, urination, diaphoresis, gastric emptying

Cholinergic BIG bad Bs –Bronchorrhea –Bradycardia –Bronchospasm

Cholinergic Muscarinic –Miosis –Bradycardia –Bronchorrhea –Vomitting/diarrhea –Sialorrhea –Urinary incontinence Nicotinic –Mydriasis –Tachycardia –Bronchodilation –HTN –Diaphoresis –Weakness

Cholinergic Rx Organophosphates (pesticides) Carbamates (physostigmine) Mushrooms

Opiod Skin- BS- decreased BS Eyes- pinpoint pupils MS- depression Heart- brady, hypotension

Opiod Morphine Codeine Hydromorphone Antidote- narcan

Benzodiazepine Skin- BS- decreased BS Eyes- pinpoint pupils MS- depression Heart- brady, hypotension Antidote- Flumazenil

Factoids Hyperthermia –Agitation/Seizures Sympatho, PCP, hallucinogens –Inability to sweat anticholinergics –Increase muscle tone Serotonin syndrome, Neuroleptic malignant syndr –Uncouple oxidative phosphorylation ASA

Hypothermia CNS depression –Sedative-hypnotics, EtOH, opiods Reduce total body glucose –Insulin, Oral hypoglycemics

Hypoglycemia HOBBIES Hypoglycemia Oral hypoglycemics –(not metformin-> Lactic acidosis) BB- Beta Blockers Insulin Ethanol Salicylates

Hyperglycemia Stimulants (beta agonists, theophylline, caffeine, epi) CCB Thiazides Vacor Steroids

Miosis COPS Clonidine, Cholinergics Opiates, organophosphates Phenothiazine, phencyclidine Sedative hypnotics,

Mydriasis AAAS Antihistamines Antidepressants Anticholinergics Sympathomimetics

Anion gap with acidosis MUDPILES Methanol, Metformin Uremia DKA Paraldehyde, phenformin INH, iron, ibuprofen, inborn errors Lactic acid Ethanol, ethylene glycol Salicylates

Osmolar Gap Calculated Osmolarity - Measured Osmolarity Calculated Osmolarity 2 [Na] + glucose/18 + BUN/2.8

Radiodense substances CHIPS Chloral hydrate Heavy metals Iron Phenothiazides Sustained-release (enteric coated) pills