Sympathomimetic toxicity

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Differential Diagnosis

Altered mental status and fever

Toxidrome Chart

Finding Cholinergic Anticholinergic Sympathomimetic Sympatholytic^ Sedative/Hypnotic
Example Organophosphates TCAs Cocaine Clonidine ETOH
Temp Nl Nl / ↑ Nl / ↑ Nl / ↓ Nl / ↓
RR Variable Nl / ↓ Variable Nl / ↓ Nl / ↓
HR Variable ↑ (sig) Nl / ↓ Nl / ↓
BP Nl / ↓ Nl / ↓
LOC Nl / Lethargic Nl, agitated, psychotic, comatose Nl, agitated, psychotic Nl, Lethargic, or Comatose Nl, Lethargic, or Comatose
Pupils Variable Mydriatic Mydriatic Nl / Miotic
Motor Fasciculations, Flacid Paralysis  Nl Nl / Agitated Nl
Skin Sweating (sig) Hot, dry Sweating Dry
Lungs Bronchospasm / rhinorrhea Nl Nl Nl
Bowel Sounds Hyperactive (SLUDGE) ↓ / Absent Nl / ↓ Nl / ↓
^Consider Sympatholytic when looking at Sedative OD or someone who doesn't respond to Narcan
Withdrawal from substances have the opposite effect


Work Up


  • Finger stick glucose (to rule out hypoglycemia)
  • Acetaminophen and Salicylate level
  • Urine Drug Screen (to verify toxic substance, do not delay treatment for results)
  • Serum electrolytes
  • Serum creatine phosphokinase
  • Creatinine and BUN
  • Urine analysis with myoglobin
  • Arterial or venous blood gas if respiratory symptoms present


  • ECG for prolongation of QTc or QRS intervals


  • Use Benzodiazepines as first line agent for agitation, hypertension, and hyperthermia
  • May also use Nitroprusside or Phentolamine
  • Treat with fluid resuscitation to avoid renal failure secondary to rhabdomyolysis (see below)




See Also


  1. 1.0 1.1 O'Connor AD, Padilla-Jones A, Gerkin AD, et al. Prevalence of Rhabdomyolysis in Sympathomimetic Toxicity: a Comparison of Stimulants. J Med Toxicol 2015;11(2)195-200