Toxicology (main)

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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)