toxidrome poison control
TRANSCRIPT
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Toxidromes in Acute Poisoning
Dr AP SamsonResident Physician
Department of Emergency Medicine
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Dr AP Samson Toxidromes
What Is A Toxidrome?A toxidrome is a
combination of signs & symptoms which, when
taken collectively, characterise a suspected
toxicantToxidromic approach has been helpful
in identifying the offending agent when
dealing with an unknown substance.
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Dr AP Samson Toxidromes
Bohol Incident – March 2005
Abdominal painDiarrhea
Vomiting?
Bacterialcontamination
Plant/marine toxin
Chemical contamination
Onset: 15 minutes – 3 hours (mean=2 h; mode=30 min)
B. cereus S. aureus
Cassava MushroomsShellfish/fish
PesticidesPetroleum distillatesArsenic
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Signs and Symptoms
Food
Maruya (n=61)
Buchi (n=32)
Abdominal pain 22 (36.06%) 24 (75%)
Diarrhea 34 (55.74%) 8 (25.0%)
Dizziness 4 (6.56%) 11 (34.38%)
Headache 15 (24.59%) 10 (31.25%)
Malaise 4 (6.56%) 5 (15.62%)
Nausea 5 (8.20%) 0
Pinpoint pupils 39 (63.93%) 7 (21.88%)
Urinary incontinence
17 (27.87%) 4 (12.5%)
Vomiting 21 (34.4%) 12 (37.5%)
CHOLINERGIC SIGNS
Cholinesterase-
inhibitingcompound
Bohol Incident
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Dr AP Samson Toxidromes
Toxidromic Approach 1. Check the
presenting signs:
• Level of sensorium • Vital signs • Pupils• Skin • Odour • Prominent symptom
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Dr AP Samson Toxidromes
Toxidromic Approach
Check the presenting signs:• Level of sensorium
Toxicants that cause COMA :• Alcohols• Arsenic• Barbiturates• Benzodiazepines • Carbon monoxide
• Isoniazid• Lead• Lithium• Opioids• Phenothiazines
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Dr AP Samson Toxidromes
Check the presenting signs:
•Vital signs
Blood pressureHeart rateRespiratory rateTemperature
Toxidromic Approach
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Dr AP Samson Toxidromes
•Vital signs
Toxicants causing changes in blood pressure
Hypertension Hypotension
Anticholinergics Carbon monoxide
Sympathomimetics Cyanide
Cyclic antidepressants
Opiates
Caffeine Nitrites
Nicotine Sedative-hypnotics
Theophylline Anti-hypertensives
Toxidromic Approach
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Dr AP Samson Toxidromes
•Vital signs
Toxicants causing changes in heart rate
Tachycardia Bradycardia
Iron -blockers
Carbon monoxide, cyanide
Anticholinesterases
Anticholinergics Clonidine
Sympathomimetics Ethanol
Salicylates Cardiac glycosides
Theophylline Opiates
Toxidromic Approach
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Dr AP Samson Toxidromes
•Vital signs
Toxicants causing changes in respiratory rate
Hyperventilation Hypoventilation
Carbamates Clonidine
Organophosphates Opiates
Methanol Heavy metals
Ethylene glycol Aromatic hydrocarbons
Theophylline Digitalis
Salicylates Sedatives
Toxidromic Approach
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Dr AP Samson Toxidromes
•Vital signs
Toxicants causing changes in temperature
Hyperthermia Hypothermia
Anticholinergics
MAO inhibitors Carbon monoxide
Metals Cholinergics
Phenothiazines Ethanol
Salicylates Hypoglycemics
Sympathomimetics
Sedative-hypnotics
-blockers
Toxidromic Approach
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Dr AP Samson Toxidromes
Check the presenting signs:
• Pupils
Toxicants causing changes in pupillary size
Miosis Mydriasis
Cholinergics Anticholinergics
Clonidine Antihistamines
Opiates Antidepressants
Organophosphates Sympathomimetics
Phenothiazines Isoniazid
Sedative-hypnotics Meperidine
Toxidromic Approach
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Dr AP Samson Toxidromes
Check the presenting signs:
• Skin Cutaneous bullae : barbiturates
Jaundice : Paracetamol, Watusi
Diaphoresis : pesticides
Hot and dry : anti-cholinergics
Flushed : alcohol
Reddish-orange: Rifampicin
Toxidromic Approach
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Dr AP Samson Toxidromes
Check the presenting signs:
• Odour
Oil of wintergreen : salicylate
Garlic : arsenic,
organophosphates
Mothballs : camphor
Rotten fish : zinc phosphide
Rotten eggs : hydrogen sulfide
Toxidromic Approach
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Dr AP Samson Toxidromes
Check the presenting signs:
• Prominent symptom
Seizure:IsoniazidTheophyllineCyanideCarbon monoxideTCAD
Toxidromic Approach
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Dr AP Samson Toxidromes
Toxidromic Approach
2. Look for toxidromes:
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Dr AP Samson Toxidromes
ComaSeizuresMetabolic acidosis
isoniazid
WHY?
Glutamic acid
GABAGlutamic aciddecarboxylase
Pyridoxal-5-phosphate
Pyridoxine Pyridoxal phosphokinase
SEIZURES
TOXIDROMES
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Dr AP Samson Toxidromes
Anticholinergics
Hot has a hare (hyperthermia)Dry as a bone (dry mucosa)Red as a beet (flushed skin)Blind as a bat (dilated pupils)Mad as a hatter (confusion/delirium)
e.g. Antihistamines, scopolamine, angel trumpet, benztropine, atropine, TCADs
TOXIDROMES
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Dr AP Samson Toxidromes
Diarrhea/diaphoresisUrinationMiosis/muscle fasciculationsBradycardia/bronchorrhea EmesisSalivation Lacrimation
organophosphates/ carbamates
WHY?
Acetylcholine Acetic acid + cholineAcetylcholinesterase
SalivationLacrimationUrinationDiarrheaGI crampsEmesis
TOXIDROMES
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Dr AP Samson Toxidromes
TOXIDROMES
Rigidity/TremorsOpisthotonusTrismusHyperreflexiaChoreoathetosis
EXTRAPYRAMIDALSYNDROME
e.g. Haloperidol, Phenothiazines, Risperidone, Olanzapine
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Dr AP Samson Toxidromes
TOXIDROMES
IrritabilityHyperreflexiaFlushingDiarrheaDiaphoresisFeverTrismusTremorsMyoclonus
SEROTONINSYNDROME
e.g. Fluoxetine, Paroxetine, Sertraline, Meperidine
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Dr AP Samson Toxidromes
TOXIDROMES of Drugs of Abuse
Toxidrome LOC Pupils Heart
Rate
Respiration Others
OPIOID C Slow,
shallow
Nausea
SYMPATHETIC D BP; T
DEPRESSANT D Loss of
coordination
HALLUCINOGEN D Decreased
Pain
INHALANT D Headache.
Muscle weakness
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Dr AP Samson Toxidromes
3. Look for other illnesses other than toxicologic
Toxidromic Approach
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Dr AP Samson Toxidromes
Toxidromic Approach
Conditions/agents producing metabolic acidosis or elevated anion gap:
• M Methanol• E Ethylene glycol • T Toluene, theophylline• A Alcoholic ketoacidosis• L Lactic acidosis
• A Aminoglycosides• C Cyanide, CO• I Isoniazid, iron• D Diabetic ketoacidosis
• G Grand mal seizures• A Aspirin (salicylates)• P Paraldehyde, Phenformin
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Dr AP Samson Toxidromes
The toxidromic approach is a helpful tool in identifying an unknown toxicant.
However, it is not the only tool.