1. Toxidromes and Drug Ingestions

2. Toxidromes What is a Toxidrome?
A constellation of clinical signs that may suggest a particular type of ingestion
Toxidromes may indicate what type of drugs a patient has taken if they are unable or unwilling to tell you

3. Toxidromes The most common toxidromes seen are: Anticholingeric
Cholinergic
Sympathomimetic
Sedative
Hallucinogenic
Serotonergic

4. Anticholinergic Toxidromes

5. Anticholinergic Toxidrome
Due to drugs that block muscarinic and nicotine acetylcholine receptor
Antihistamines (1st generation)
Tricyclic antidepressants
Antitussives (cough mixtures)
Antipsychotics
Anticonvulsants
Antimuscularinic drugs
Atropine
Scopolamine
Ipatroprium bromide
Plants
Mushrooms
Datura

6. Anticholinergic Toxidrome
The anticholinergic toxidrome consists of:
Delirium + peripheral antimuscarinic effects
Mad as a hatter
Confusion/hallucinations/seizure/coma
Red as a beet
Flushed skin
Blind as a bat
Mydriasis
Hot as a hare
Hyperthermia
Dry as a bone
Dry skin, urinary retention, ileus

7. Cholinergic Toxidromes

8. Cholinergic Toxidrome
Due to drugs that activate acetylcholine receptor
ie the opposite of anticholinegric toxidromes

9. Cholinergic Toxidrome
Caused by:
Organophosphate insecticides
Carbamate insecticides
Chemical warfare agents eg Ricin, Tabun, Soman, VX
Alzheimer's medication eg donepezil
Agents used for myasthenia gravis
Neostigmin
Edrophonium
Pilocarpine
Phyostigmine

10. Cholinergic Toxidrome
The cholinergic toxidrome =“DUMBELS”: D
Diaphoresis
Diarrhoea (and abdo cramps) U
urination M
Miosis (or mydriasis) B
Bronchospasm
Bronchorrhoea
Bradycardia E
Emesis L
Lacrimation S
Salivation

11. Sympathomimetic Toxidromes

12. Sympathomimetic Toxidrome
Act via stimulation of sympathetic nervous system
Toxidrome – everything stimulated
Hypertension
Tachycardia
Tachypnoea
Hyperthermia
Agitation
Dilated pupils (usually)
Diaphoresis/flushing
c.f: anticholinergic – dry

13. Sympathomimetic Toxidrome
In New Zealand the most commonly seen sympathomimetic ingestion is methamphetamine
Can also be seen with
Alpha receptor agonists
Phenylephrine eg OTC cold preparations eg - coldrex
Beta receptor agonist
Salbutamol
Theophylline
Caffeine
Alpha and beta agonists
Amphetamine
Cocaine
Pseudo/ephedrine
MDMA (ecstasy)

14. Sedative or Hypnotic Toxidromes

15. Sedative or Hypnotic Toxidrome
Caused by any medication that causes CNS depression, such as:
Benzodiazepines
Barbiturates
Alcohols
Opioids
Anticonvulsants
Antipsychotics

16. Sedative or Hypnotic Toxidrome
Decreased Level of consciousness
Hypoventilation
Hypotension
Bradycardia
Opioids + barbiturates also cause
Miosis
Hypothermia

17. Hallucinogenic Toxidromes

18. Hallucinogenic Toxidrome
As it sounds, this is caused by drugs and agents that cause hallucinations
Amphetamine
Cannaboids
Cocaine
LSD
PCP
Magic mushrooms (Psilocybin spp.)

19. Hallucinogenic Toxidrome
Primarily presents with hallucination
Also can present with:
Frank psychosis
Panic attacks and anxiety
Sympathomimetic symptoms esp. tachycardia, hypertension and fever

20. Serotonergic Toxidromes

21. Serotonergic Toxidrome
A collection of signs and symptoms produced by excess serotonin in the central, peripheral and autonomic nervous systems

22. Serotonergic Toxidrome
Multiple medications can cause serotonergic toxidrome (or serotonin syndrome)
Most commonly occurs when ≥ 2 medications which affect either serotonin reuptake or metabolism are given, but can also occur with a single agent

23. Serotonergic Toxidrome
Associated with:
Selective serotonin reuptake inhibitors (SSRI -antidepressants)
Eg paroxtetine, fluoxetine
Serotonin noradrenalin reuptake inhibitors (SNRI –antidressants)
Eg venlafaxine, citaloprma
Tricyclic antidepressants
Monoamine oxidase iunhibitors (Block serotonin break down –used as antidepressants)
Eg moclobmide
Analgesic
Eg pethidine, tramadol, fentanyl
Antiemetics
Eg metoclopramide, ondansteron
Anticonvulsants
Eg valproaic acid
Dietary supplements
Eg St johns wort, ginseng

24. Serotonergic Toxidrome
Produces wide variety of signs and symptoms due to CNS, peripheral and autonomic dysfunction
Most commonly produces
Tremor
Hyperreflexia and muscle rigidity esp in the legs
Clonus
Fever
Tachycardia and hypertension