Toxicology (main)

Exam

1. All VS (Temp, RR,HR, BP)
2. Neuro Exam
   1. Level of consciousness
   2. Pupillary exam
   3. Motor response
3. Skin Exam - moisture, temp
4. Lung Exam
5. Bowel Sounds

DDx

Hyperthermia

1. Altered Metabolism
   1. salicylates
   2. withdrawal states
   3. thyroid hormones
   4. dinitrophenols
2. Increased Muscle Activity
   1. withdrawal, sympathomimetics
   2. MAOI
   3. PCP, LSD
   4. lithium, amoxapine
3. Impaired Heat Dissipation
   1. anticholinergics
   2. antihistamines
   3. antipsychotics (TCAs)
4. Malignant Hyperthermia
   1. anesthestics
5. Neuroleptic Malignant Syndrome
   1. phenothiazines, Lithium, LevoDopa

Hypothermia

1. Exposure
   1. alcohol, sedative hypnotics
   2. narcotics, TCAs, phenothiazines
   3. Insulin (hypoglycemia)

Increased Respiratory Rate

1. Direct Stimulation
   1. salicylates
   2. metabolic acidosis
   3. dintirophenol, pentachlorophenol
   4. hepatorenal failure
   5. CNS stimulants (cocaine, amphet, theophylline)

Tissue Hypoxia

1. CO
2. cyanide
3. hydrogen sulfide
4. methemoglobinemia

Respiratory Depression

1. Central Depression
   1. antipsychotics
   2. chlorinated hydrocarbons
   3. alcohols/glycols, sedative/hyp
   4. TCAs
   5. Lomitil
2. Muscle Failure
   1. organophosphates
   2. marine toxins
   3. nicotine
   4. strychnine
   5. botulinis
   6. Mojave rattlesnake, Cobra

Autonomic Nervous System

1. Parasympathetic - ACh is transm
   1. Muscarinic
      1. receptors in heart, eye, lung, GI, skin and sweat glands
      2. Bradycardia
      3. Miosis
      4. Bronchorrhea / Bronchospasm
      5. Hyperperistalsis (SLUDGE)
      6. Sweating
      7. Vasodilation
   2. Nicotinic
      1. receptors in both sympathetic and parasympathetic nervous systems
      2. fasciculations, flaccid paralysis
      3. tachycardia, hypertension?
2. Sympathetic
   1. ALPHA EFFECTS - vessels, eye, skin
      1. Mydriasis, HTN, Sweating
   2. BETA EFFECTS - heart, lungs
      1. Tachycardia, Bronchodilation

Toxidromes

Finding	Mixed Cholinergic (Organoph)	Anticholinergic (TCAs, antihist, phenothiazines)	Sympathomimetic^ (Cocaine, amphet, ecstasy, ketamine)	Sympatholytic^^ (Clonidine)	Sedative/Hypnotic
Temp	Nl	Nl/Inc	Nl/Inc	Nl/Dec	Nl/Dec
RR	Varriable	Nl/Dec	Varriable	Nl/Dec	Nl/Dec
HR	Varriable	Tachy	Inc	Nl/Dec	Nl/Dec
BP	HTN		Inc	Nl/Dec	Nl/Dec
LOC		Nl, delirious, agitated, psychotic, comatose	Nl, agitated, del or psycho	Nl, Lethargic, or Comatose	Nl, Lethargic, or Comatose
Pupils	Varriable	Mydriasis	Mydriatic	Nl/Miotic
Motor	Facciculations, Flacid Paral	Nl	Nl/Agitated	Nl
Skin	Sweating (sig)	Hot, dry	Sweating	Dry
Lungs	Bronchospasm/ rhinorrhea	Nl	Nl	Nl
Bowel Sounds	Hyperactive (SLUDGE)	Dec/Absent	Nl/Dec	Nl/Dec

^usually more tachy and higher BP than anticholinergic and not dry as in anticholinergic.

^^Consider Sympatholytic when looking at Sedative OD or someone who doesn't respond to Narcan

Source

DONALDSON (Adapted from BIRNBAUMER - 7/18/02)