Toxicology (main)
Exam
- All VS (Temp, RR,HR, BP)
- Neuro Exam
- Level of consciousness
- Pupillary exam
- Motor response
- Skin Exam - moisture, temp
- Lung Exam
- Bowel Sounds
DDx
I. HYPERTHERMIA
1) Altered Metabolism
- salicylates
- withdrawal states
- thyroid hormones
- dinitrophenols
2) Increased Muscle Activity
- withdrawal, sympathomimetics
- MAOI
-PCP, LSD
- lithium, amoxapine
3) Impaired Heat Dissipation
- anticholinergics
- antihistamines
- antipsychotics (TCAs)
4) Malignant Hyperthermia
- anesthestics
5) Neuroleptic Malignant Syndrome
- phenothiazines, Lithium, LevoDopa
II. HYPOTHERMIA
1) Exposure
- alcohol, sedative hypnotics
- narcotics, TCAs, phenothiazines
- Insulin (hypoglycemia)
III. INCREASED RESPIRATORY RATE
1) Direct Stimulation
- salicylates
- metabolic acidosis
- dintirophenol, pentachlorophenol
- hepatorenal failure
- CNS stimulants (cocaine, amphet,
theophylline)
IV. TISSUE HYPOXIA
- CO
- cyanide
-hydrogen sulfide
- methemoglobinemia
V. RESPIRATORY DEPRESSION
1) Central Depression
- antipsychotics
- chlorinated hydrocarbons
- alcohols/glycols, sedative/hyp
- TCAs
- Lomitil
2) Muscle Failure
- organophosphates
- marine toxins
- nicotine
- strychnine
- botulinis
- Mojave rattlesnake, Cobra
VI. AUTONOMIC NERVOUS SYSTEM
1) Parasympathetic - ACh is transm
a) Muscarinic
-receptors in heart, eye, lung, GI, skin and sweat glands
- Bradycardia
- Miosis
- Bronchorrhea / Bronchospasm
- Hyperperistalsis (SLUDGE)
- Sweating
- Vasodilation
b) Nicotinic
- receptors in both sympathetic and parasympathetic nervous systems
- fasciculations, flaccid paralysis
- tachycardia, hypertension?
2) Sympathetic
ALPHA EFFECTS - vessels, eye, skin
- Mydriasis, HTN, Sweating
BETA EFFECTS - heart, lungs
- Tachycardia, Bronchodilation
Toxidromes
1. MIXED CHOLINERGIC (ORGANOPH) Temp Normal
RR Increased (spasm -M
inc secretions)
Decreased (N- paralysis)
HR Tachycardia (N-pregang
or Normal or Brady (M)
BP HTN (N)
LOC Normal to Lethargic
Pupils Miotic (M) or Nl or Mydr (N)
Motor Facciculations, Flacid Paral
Skin Sweating (mod to marked
Lungs Bronchospasm/ rrhea
BSs Hyperactive (SLUDGE)
ANTICHOLINERGIC
(TCAs, antihist, phenothiazines)
Temp Nl to Inc (dec sweating)
RR Nl to Dec
HR Tachy (unopposed B1)
LOC Nl or delirious, agitated,
psychotic, comatose
Pupils Mydriasis (unoppos alpha)
Motor Nl
Skin Dry, hot
Lungs Nl
BSs Decr to Absent
SYMPATHOMIMETIC
(Cocaine, amphet, ecstasy, ketamine
Temp Nl to Inc (muscle activ inc)
RR Inc or Dec
HR Inc (Beta 1)
BP Inc (alpha 1)
LOC Nl, agitated, del or psycho
Pupils Mydriatic (alpha 1)
Motor Nl to Agitated
Skin Sweating
Lungs Nl
BSs Nl to Dec
- usually more tachy and higher BP than anticholinergic and not dry as in anticholinergic.
- Dexatrim or Ephedrine - alpha stim, can give phentolamine or Nipride
SYMPATHOLYTIC (Clonidine)
Temp Nl to Dec
RR Nl to Dec
HR, BP Nl to Dec
LOC Nl, Lethargic, or Comatose
Pupils Nl to Miotic
Motor Nl
Skin Dry
Lungs Nl
BSs Nl to Dec
- Consider Sympatholytic when looking at Sedative OD or someone who doesn't respond to Narcan.
SEDATIVE / HYPNOTIC
Temp Nl to Dec
RR, HR Nl to Dec All Nl
LOC Nl to Leth
Source
DONALDSON (Adapted from BIRNBAUMER - 7/18/02)