Toxidromes

CME 5th April 2017

Sinéad Taylor
 Outline
 Anticholinergic Toxidrome
 Cholinergic Toxidrome
 Opiate Toxidrome
 Hypnosedative Toxidrome
 Sympathomimetic Toxidrome
 Serotonin Syndrome
 Neuroleptic Malignant Syndrome
 Anticholinergic Toxidrome
 Anticholinergic drugs have
an affinity for the
acetylcholine receptor and
antagonise
muscarinic/nicotinic
receptors.
 The majority of blockade is at
muscarinic receptors, but at
high doses some blockade
occurs at nicotinic receptors
in the autonomic ganglia and
at the motor end plates.
 Anticholinergic Toxidrome
 Muscarinic receptors:
 M1: Central and enteric nervous
systems
 M2: Heart
 M3: Smooth muscle
 Increases exocrine gland
secretion
 Increases gut motility
 Miosis via pupillary sphincter
 Accommodation via ciliary
muscles
 Bronchoconstriction
 Bladder constriction

 Therefore muscarinic blockade will

give the classic anticholinergic “dry
as a bone, red as a beet, hot as a
hare, mad as a hatter, blind as a
bat”
 Anticholinergic Toxidrome
 Central effects:
 Agitated delirium (mad as a hatter)
characterised by:
 Fluctuating mental status
 Confusion
 Restlessness and fidgeting
 Picking at objects in the air
 Mumbling slurred speech
 Disruptive behaviour
 Tremor
 Myoclonus
 Coma
 Seizure (rare)

 Peripheral effects:
 Mydriasis (blind as a bat)
 Tachycardia
 Dry mouth (dry as a bone)
 Dry skin
 Flushing (red as a beet)
 Hyperthermia (hot as a hare)
 Urinary retention
 Spares or absent bowel sounds
 Anticholinergic Toxidrome
 Sources:
 ATROPINE
 Antiepileptics (carbamazepine)
 Antihistamines
 Anti-Parkinson medications:
Amantadine, benztropine
 Antipsychotics: Chlorpromazine,
clozapine, olanzapine, droperidol,
haloperidol, quetiapine
 Anti motion sickness agents:
Scopolamine
 GI antispasmodics: e.g., hyoscyamine
 GU antispasmodics: e.g., oxybutynin,
solifenacin
 Plant sources: Belladonna, Brugmansia
(angel’s trumpets), datura (Jimson
Weed), Henbane (Stinking Nightshade),
Mandrake
 Skeletal muscle relaxants: dantrolene
 SSRIs: Paroxetine
 TCAs: Amitriptyline, clomipramine,
nortriptyline
 Topical eyedrops: cyclopentolate,
homatropine, tropicamide
 Anticholinergic Toxidrome
 Signs and symptoms are
variable. No particular pattern
can accurately or reliably
diagnose this toxidrome.
 Differential Dx:
 Encephalitis
 Hypoglycaemia
 Hyponatraemia
 Ictal phenomenon
 NMS
 Neurotrauma
 Sepsis
 Serotonin syndrome
 Subarachnoid haemorrhage
 Wernicke’s encephalopathy
 Anticholinergic Toxidrome
 Management: RRSIDEAD (as always!)

 Avoid treating agitation with

anticholinergic drugs (e.g., droperidol,
haloperidol)

 Antidote: Physostigmine
 Reversible acetylcholinesterase inhibitor
 Indications:
 Agitated delirium not controlled by
benzodiazepine sedation
 Isolated anticholinergic poisoning
 Contraindications:
 Bradyarrhythmias
 Intraventricular block (QRS >100ms)
 AV block
 Bronchospasm
 Duration of action shorter than delirium,
however repeat doses may not be
required
 Cholinergic Toxidrome
 Result of increased
acetylcholine activity at both
central and peripheral
nicotinic and muscarinic
receptors.
 Can arise from either:
 Cholinesterase inhibitors
(e.g., organophosphate and
carbamates)
 Cholinomimetics - have
direct agonist action at
muscarinic or nicotinic sites
(e.g., pilocarpine, muscarine)
 Cholinergic Toxidrome
Central nervous system: Parasympathetic muscarinic
• Agitation effects:
• Central resp depression • Abdo cramps
• Coma • Bradycardia
• Confusion • Bronchoconstriction
• Lethargy • Bronchorrhoea
• Seizures • Diarrhoea
• Lacrimation
• Miosis
• Salivation
• Urinary incontinence
• Vomiting
Neuromuscular: Sympathetic nicotinic effects:
• Fasciculation • Hypertension
• Muscle weakness • Mydriasis
• Sweating
• Tachycardia
 Cholinergic Toxidrome
 Killer B’s: bronchorrhoea,
bronchospasm
 SLUDGE
 Salivation
 Lacrimation
 Urination
 Diarrhoea
 Gastrointestinal distress
 Emesis

 DUMBELLS
 Diarrhoea
 Urination
 Miosis
 Bradycardia
 Emesis
 Lacrimation
 Lethargy
 Salivation
 Cholinergic Toxidrome
Sources:
 Acetylcholinesterase inhibitors:
 Organophosphates
 Carbamate insecticides
 Chemical warfare nerve agents (e.g.,
sarin)
 Agents used in dementia: Donepezil,
galantamine, rivastigmine, tacrine
 Agents used in myasthenia gravis:
edrophonium, neostigmine,
physostigmine, pyridostigmine

 Acetylcholine agonists:
 Muscarinic agents: Acetylcholine,
carbachol, pilocarpine
 Nicotinic agents: Nicotine
 Mushrooms (muscarine)
 http://www.news.com.au/world/middle-
east/world-horrified-after-suspected-gas-
attack-leaves-dozens-dead-in-syria/news-
story/c84778dec4cb259c3a87e83deaf36d0
5

“Today around 7:30am, about 125 injuries arrived to

our hospital. Twenty five of them were already dead,
70 per cent to 80 per cent of the wounded people
were kids and women.

“The symptoms were pale skin, sweating, narrow or

pin-eye pupils, very intense respiratory detachments.”
 Cholinergic Toxidrome
 Differential diagnosis
 Causes of weakness (Guillain-
Barré, myasthenia gravis,
botulism)
 Cardiotropic intoxication resulting
in bradycardia and vomiting
(digoxin, oleander, β-blockers,
CCBs,
 Gastroenteritis and abdo
emergencies
 Ictal phenomena
 Mushroom ingestion
 Respiratory disorders (asthma,
CCF)
 Salicylate intoxication
 Serotonin syndrome
 Sympatomimetic syndrome
 Theophylline intoxication
 Cholinergic Toxidrome
 Management
 RRSIDEAD
 Atropine: If signs of muscarinic
excess. Keep giving it until
drying of secretions is
achieved
 Seizure control with benzos
 Decontamination, but don’t let
it delay resus
 Organophosphate/carbamate/
nerve agent poisoning:
Pralidoxime.
 Initial bolus: 2g pralidoxime
in 100ml 0.9% NaCl over
15 minutes
 Infusion: 500mg/hr (6g in
500ml 0.9% NaCl at
42ml/hr)
 Opiate Toxidrome
 Due to narcotics and narcotic
derivatives, binding to opiate
receptors in CNS and bowel.
 Classical presentation:
 CNS depression
 Respiratory depression
 Miosis
 Other/complications
 Tachycardia (response to
hypoxia, hypercarbia)
 Decreased bowel sounds
 Peripheral vasodilation with
hypothermia, hypotension
 Resp depression and
subsequent coma can be fatal
 Opiate Toxidrome
 Special cases:
 Dextropropoxyphene
(Darvon): 20mg/kg may
cause CNS depression,
seizures, cardiac
dysrhythmias (fast Na
channel blocking effect)
 Pethidine: Repeated
therapeutic doses associated
with seizures
 Implicated in serotonin
syndrome
 Opiate Toxidrome
 Management
 RRSIDEAD
 Sodium bicarbonate if
dextropropoxyphene
poisoning leading to
ventricular arrhythmias
 Naloxone for CNS
depression
 Opiate Toxidrome
 Naloxone:
 Competitive opioid
antagonist at mu, kappa, and
delta receptors
 Treatment dose:
 Initial bolus 100microg IV
(or 400microg IM/subcut)
 Then give repeated
100microg boluses every
30-60 seconds until
adequate spontaneous
respiration
 If necessary, infusion:
 2/3 of the initial dose
required to wake the
patient up, per hour.
 Hypnosedative Toxidrome
 Hypnosedatives: Modulate
activity of GABA
neutrotrasmitter complex
 Include:
 Benzodiazepines
 Barbiturates
 Zolpidem, zopliclone
 Baclofen
 Gamma-hydroxybutyrate
(GHB)
 Chloral hydrate
 Paraldehyde
 Hypnosedative Toxidrome
 Presentation - Think ETOH!
 Respiratory depression
 Bradycardia
 Hypotension
 Poor coordination
 Slurred speech
 Ataxia
 Lethargy
 Disinhibition
 Decreased muscle tone
 Nystagmus
 Neurological depression
 Stupor
 Coma
 Treatment: supportive therapy
(caution with Flumazenil!)
 Hypnosedative Toxidrome
 Baclofen
 Being increasingly used as a
drug of abuse because it
induces euphoria at higher
doses (only small intrathecal
doses needed for therapeutic
effect)
 Severe OD can mimic brain
death, nearly result in organ
harvesting in some cases!
 Sympathomimetic Toxidrome
 Sympathomimetics: drugs that
have an activating effect on the
sympathetic nervous system
through the direct or indirect effect
on catecholamines.
 Direct acting: alpha-agonists,
dopaminergic agents
 Indirect acting agents: cause
increased catecholamine release,
inhibition of enzymatic breakdown,
or delayed reuptake (e.g.,
pseudoephedrine, amphetamines,
cocaine).

 Cross-reactivity:
 Cocaine can affect dopamine
 MDMA can contribute to serotonin
syndrome
 Sympathomimetic Toxidrome
 Classic presentation:
 Tachycardia
 Hypertension
 Hyperthermia
 Hyperreflexia
 Mydriasis
 Diaphoresis
 Normal bowel sounds
 Other associated Sx
 Pressured speech
 Flight of ideas
 Paranoia
 Bruxism
 Tremors
 Chest pain
 Rhabdomyolysis
 Sympathomimetic Toxidrome
 Treatment:
 Hypertension and tachycardia:
 Titrated benzos first
 Phentolamine 1mg IV repeated every 5
minutes
 Titrated vasodilator infusion (e.g., GTN)
 NEVER give β-blockers (can lead to
unopposed alpha stimulation and
vasoconstriction)
 Seizures: IV diazepam (second line: barbiturates)
 Agitation: Benzos (second line: droperidol,
olanzapine)
 Hyperthermia
 >38.5: continuous core temp monitoring, benzo
sedation, fluid resus
 >39.5: rapid external cooling. May need
paralysis, intubation, ventilation.
 Hyponatraemia: If profound (<120mmol) + altered
mental state/seizures, give hypertonic saline
 3% NaCl 4ml/kg over 30 mins. Keep repeating
to maintain Na >120mmol)
 Sympathomimetic Toxidrome
 Cocaine
 Blockade of presynaptic catecholamine
uptake (sympathomimetic).
 Also has calcium channel blockade,
which may lead to ventricular
dysrhythmia.
 Treat with sodium bicarb. If
refractory to sodium bicarb and defib
 lignocaine 1.5mg/kg IV
 Serotonin Syndrome
 Clinical manifestation of
excessive stimulation of
serotonin receptors in the
CNS
 Life threatening toxicity rare
following single SSRI
ingestion.
 Is more common with combo
of MAOI and SSRIs.
 Serotonin Syndrome
 Causative agents:
 Analgesics and antitussives –
dextromethorphan, fentanyl,
pethidine, tramadol
 Antidepressants
 SSRIs
 SNRIs
 TCAs
 MAOIs
 Drugs of abuse –
amphetamines, MDMA,
ectsasy
 Herbal preparations (St John’s
Wort)
 Tryptophan, lithium
 Serotonin Syndrome
 Presentation: the classical
triad
1. Autonomic stimulation:
diarrhoea, flushing,
hyperthermia, mydriasis,
sweating, tachycardia
2. Neuromuscular excitation:
clonus, hyperreflexia,
increased tone, myoclonus,
rigidity, tremor
3. Mental state changes:
anxiety, agitation,
psychomotor acceleration,
delirium, confusion
 Serotonin Syndrome
 Diagnosis: Hunter Criteria
 Differentials:
 NMS (has a slower onset,
development of acute
parkinsonism with
bradykinesia and lead-pipe
rigidity, and an absence of
neuromuscular excitation)
 Anticholinergic toxidrome
 Malignant hyperthermia:
Does not produce
neuromuscular excitation,
and requires a history of
volatile anaesthetic
exposure.
 Serotonin Syndrome
 Management (RRSIDEAD)
 Supportive care
 May need intubation +
ventilation +/- paralysis if
coma, recurrent seizures,
hyperthermia >39.5C
 Antidote: cyproheptadine 8mg
(serotonin antagonist).
 Efficacy not yet proven
 Not indicated in severe SS
 May be useful in mild-mod
serotonin syndrome
refractory to
benzodiazepines.
 Requires ICU admission if
severe. Sx likely resolve with
complete recovery within 24-
48 hours.
 Neuroleptic Malignant
Syndrome
 Rare and potentially lethal,
due to the use of neuroleptic
medications.
 Controversial aetiology, may
be due to deficiency/blockade
of dopaminergic
neurotransmission in
nigrostriatal, mesolimbic, and
hypothalamic-pituitary
pathways.
 Suspect if the patient presents
with the following toxidrome,
and has a history of ingestion
of one or more neuroleptic
agents.
 Neuroleptic Malignant
Syndrome
 Clinical features:
 Central nervous system:
Confusion, delirium, stupor, coma
 Autonomic instability:
Hyperthermia, tachycardia,
hypertension, respiratory
irregularities, cardiac dysrhythmias
 Neuromuscular:
 Lead-pipe rigidity
 Generalised bradykinesia or
akinesia
 Mutism and staring
 Dystonia and abnormal
postures
 Abnormal involuntary
movements
 Incontinence
 Neuroleptic Malignant
Syndrome
 Management:
 Supportive
 May need intubation +
paralysis if temperature >39.5
 Role of benzos controversial
 ?may play a part in causing
NMS
 Use specific agents like
bromocriptine (dopamine
agonist) in moderate or
severe cases
 Dantrolene – severe muscle
rigidity
 ECT – if refractory. May
increase central dopaminergic
activity.
Condition Obs Pupils Skin Bowel sounds Neuromuscular Reflexes Mental status
tone

Anticholinergic Tachycardia Mydriasis Hot, dry, red Sparse or absent Normal Normal Agitated delirium
Hyperthermia

Cholinergic Muscarinic: Miosis Diaphoretic Hyperactive Fasciculations Normal Agitation,

Bradycardia Muscle weakness confusion
Nicotinic: Coma, seizures
Tachycardia
and
hypotension

Opiate toxicity Tachycardia Miosis Peripheral Decreased Normal Normal CNS depression.
Bradypnoea vasodilation Coma
Hypotension May be
Hypothermia hypothermic, cool

Hypnosedative Bradycardia Nystagmus Normal Normal Decreased Normal Slurred speech,

Bradypnoea muscle tone stupor,
Hypotension Ataxia disinhibition, CNS
Hypothermia depression, coma

Sympathomimetic Tachycardia Mydriasis Diaphoresis Normal Neuromuscular Hyperreflexia Agitation,

Tachypnoea excitation, tremor pressured
Hypertension speech, flight of
Hyperthermia ideas, paranoia

Serotonin Tachycardia Mydriasis Diaphoresis Hyperactive Increased, Hyperreflexia and Agitation

syndrome Tachypnoea especially lower clonus progressing to
Hypertension limbs coma
Hyperthermia

Neuroleptic Tachycardia Mydriasis or Sweaty but pale Normal Lead-pipe rigidity Bradyreflexia Mutism, staring,
malignant Hypertension normal bradykinesia,
syndrome Tachypnoea coma
Hyperthermia
 References
 Murray L. Toxicology handbook. Sydney, N.S.W.: Churchill
Livingstone/Elsevier; 2011.
 Kloss B, Bruce T. Toxicology in a Box. 1st ed. McGraw Hill;
2014.
 The Hunter Serotonin Toxicity Criteria: simple and accurate
diagnostic decision rules for serotonin toxicity
 Isbister G, Bucket N, Whyte I. Serotonin toxicity: a practical
approach to diagnosis and treatment. The Medical Journal
of Australia. 2007;187(6):361-365.
 Katzung B, Masters S, Trevor A. Basic & clinical
pharmacology. New York: McGraw-Hill Medical; 2009.