I brought the DantasticTox guys back to discuss how toxidrome really present, you know in real life.
If you missed their first EMCrit episode, go listen:
and then check out the Dantastic Tox Podcast
Anticholinergic
Altered, but will give you 3 seconds of attention
Big, non-reactive pupils (constrictors knocked out); Pupils may not even be enormous until you stimulate and then they get wide
Dry-everywhere. Put a gloved hand in the axilla if you are brave like Howard
Voice–Worst cottonmouth ever
Picking behaviors (this is the big one) – they will be plucking at EVERYTHING. Taking off gown.
Stimulus evoked tachycardia
Bowel Sounds-screw bowel sounds, because DEMONS
Cholinergic
Like Spongebob when you squeeze-water comes from everywhere
“SLUDGE”: Salivation, Lacrimation, Urination, Defecation, GI cramping, Emesis + “Killer B’s”: Bronchorrhea, Bradycardia, Bronchospasm
Pinpoint pupils
Pooping on themselves
Lacrimation
So remember cardiogenic shock with crying and diarrhea and pinpoint pupils.
Sympathomimetic
Mydriasis, but briskly reactive (i.e. they will constrict when you shine light)
Sweaty
Psychomotor agitation, Paranoia, Psychotic, but they will respond to questions (but you won't like the answers)
Tachycardia, htn,
BODY TEMPERATURE
Blunts fatigue, pain response, and exhaustion
Sedative/ETOH Withdrawal can only really be differentiated by history
Opioid
bradypnea first then look at the pupils
Sedative/Hypnotics
Sleepy
Ventilations preserved
Benzo plus is where the problem comes
Additional New Information
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Thanks guys – nice discussion. My $0.02:
1. never had a good anticholingic pt w active BS. Easy to check. 10 secs.
2. Ever seen fasciculations in a sweaty pt w small pupils? Pretty much makes the dx.
Keep’em coming!
I have always appreciated the use of toxidromes but personally find combining them with the setting and history even better…aka..the Poisontation!
60 y/o with several days worsening mental status – start by looking for Dig or Aspirin,
child found in a garage – toxic alcohol or pesticide
in my area (Chicago) teenaged female – APAP, diphenhydramine or buproprion
as common examples
Prison tox, hotel tox, etc