Toxidromes in Acute Poisoning

Dr AP Samson
Resident Physician
Department of Emergency Medicine
 What Is A Toxidrome?
A toxidrome is a combination of
signs & symptoms which, when
taken collectively, characterise a
suspected toxicant

Toxidromic approach has been helpful

in identifying the offending agent when
dealing with an unknown substance.

Dr AP Samson Toxidromes
 Bohol Incident –
March 2005

Abdominal pain
Onset: 15 minutes – 3 hours
Diarrhea
(mean=2 h; mode=30 min)
Vomiting?

Bacterial Plant/marine Chemical

contamination toxin contamination

B. cereus Cassava Pesticides

S. aureus Mushrooms Petroleum distillates
Dr AP Samson Shellfish/fish Arsenic Toxidromes
 Cholinesterase-
Bohol Incident inhibiting
compound

Signs and Food

Symptoms Maruya (n=61) Buchi (n=32)
CHOLINERGIC SIGNS
Abdominal pain 22 (36.06%) 24 (75%)
Diarrhea 34 (55.74%) 8 (25.0%)
Dizziness 4 (6.56%) 11 (34.38%)
Headache 15 (24.59%) 10 (31.25%)
Malaise 4 (6.56%) 5 (15.62%)
Nausea 5 (8.20%) 0
Pinpoint pupils 39 (63.93%) 7 (21.88%)
Urinary incontinence 17 (27.87%) 4 (12.5%)
Vomiting 21 (34.4%) 12 (37.5%)
 Toxidromic Approach
1. Check the presenting
signs:

• Level of sensorium
• Vital signs
• Pupils
• Skin
• Odour
• Prominent symptom

Dr AP Samson Toxidromes
 Toxidromic Approach
Check the presenting
signs:
• Level of sensorium

Toxicants that cause COMA :

• Alcohols • Isoniazid
• Arsenic • Lead
• Barbiturates • Lithium
• Benzodiazepines • Opioids
• Carbon monoxide • Phenothiazines

Dr AP Samson Toxidromes
 Toxidromic Approach
Check the presenting signs:

•Vital signs

Blood pressure
Heart rate
Respiratory rate
Temperature

Dr AP Samson Toxidromes
 Toxidromic Approach
•Vital signs

Toxicants causing changes in blood pressure

Hypertension Hypotension
Anticholinergics Carbon monoxide
Sympathomimetics Cyanide
Cyclic antidepressants Opiates
Caffeine Nitrites
Nicotine Sedative-hypnotics
Theophylline Anti-hypertensives

Dr AP Samson Toxidromes
 Toxidromic Approach
•Vital signs

Toxicants causing changes in heart rate

Tachycardia Bradycardia
Iron -blockers

Carbon monoxide, cyanide Anticholinesterases

Anticholinergics Clonidine

Sympathomimetics Ethanol

Salicylates Cardiac glycosides

Theophylline Opiates

Dr AP Samson Toxidromes
Toxidromic Approach
•Vital signs

Toxicants causing changes in respiratory rate

Hyperventilation Hypoventilation
Carbamates Clonidine

Organophosphates Opiates

Methanol Heavy metals

Ethylene glycol Aromatic hydrocarbons

Theophylline Digitalis

Salicylates Sedatives

Dr AP Samson Toxidromes
 Toxidromic Approach
•Vital signs

Toxicants causing changes in temperature

Hyperthermia Hypothermia
Anticholinergics -blockers

MAO inhibitors Carbon monoxide

Metals Cholinergics

Phenothiazines Ethanol

Salicylates Hypoglycemics

Sympathomimetics Sedative-hypnotics

Dr AP Samson Toxidromes
 Toxidromic Approach
• Pupils

Check the presenting signs:

Toxicants causing changes in pupillary size

Miosis Mydriasis
Cholinergics Anticholinergics
Clonidine Antihistamines
Opiates Antidepressants
Organophosphates Sympathomimetics
Phenothiazines Isoniazid
Sedative-hypnotics Meperidine

Dr AP Samson Toxidromes
Toxidromic Approach

Check the presenting signs:

• Skin
Cutaneous bullae : barbiturates
Jaundice : Paracetamol, Watusi
Diaphoresis : pesticides
Hot and dry : anti-cholinergics
Flushed : alcohol
Reddish-orange : Rifampicin
Dr AP Samson Toxidromes
Toxidromic Approach
Check the presenting signs:
• Odour
Oil of wintergreen : salicylate
Garlic : arsenic,
organophosphates
Mothballs : camphor

Rotten fish : zinc phosphide

Rotten eggs : hydrogen sulfide

Dr AP Samson Toxidromes
 Toxidromic Approach

Check the presenting signs:

• Prominent symptom
Seizure:
Isoniazid
Theophylline
Cyanide
Carbon monoxide
TCAD

Dr AP Samson Toxidromes
 Toxidromic Approach

2. Look for toxidromes:

Dr AP Samson Toxidromes
 TOXIDROME
S
Coma
Seizures isoniazid
Metabolic acidosis

WHY? Pyridoxine
Pyridoxal phosphokinase
Pyridoxal-5-phosphate
Glutamic GABA
acid Glutamic acid SEIZURES
decarboxylase

Dr AP Samson Toxidromes
 TOXIDROME
S
Anticholinergics

Hot has a hare (hyperthermia)

Dry as a bone (dry mucosa)
Red as a beet (flushed skin)
Blind as a bat (dilated pupils)
Mad as a hatter (confusion/delirium)
e.g. Antihistamines, scopolamine, angel trumpet, benztropine,
atropine, TCADs

Dr AP Samson Toxidromes
 TOXIDROME
S
Salivation
Lacrimation
Urination
Diarrhea/diaphoresis
Diarrhea
Urination
GI cramps
Miosis/muscle fasciculations
Emesis
Bradycardia/bronchorrhea
Emesis organophosphates/
Salivation
Lacrimation
carbamates

WHY?
Acetylcholine Acetic acid + choline
Dr AP Samson Acetylcholinesterase Toxidromes
 TOXIDROME
S
Rigidity/Tremors
Opisthotonus
Trismus EXTRAPYRAMIDAL
Hyperreflexia SYNDROME
Choreoathetosis

e.g. Haloperidol, Phenothiazines, Risperidone,

Olanzapine
Dr AP Samson Toxidromes
 TOXIDROMES

Irritability
Hyperreflexia
Flushing
Diarrhea SEROTONIN
Diaphoresis SYNDROME
Fever
Trismus
Tremors e.g. Fluoxetine, Paroxetine,
Myoclonus Sertraline, Meperidine

Dr AP Samson Toxidromes
 TOXIDROMES of Drugs of Abuse

Toxidrome LOC Pupils Heart Respiration Others

Rate
OPIOID C Slow, Nausea
shallow
SYMPATHETIC D BP; T

DEPRESSANT D Loss of
coordination
HALLUCINOGEN D Decreased
Pain
INHALANT D Headache.
Muscle
weakness
Dr AP Samson Toxidromes
 Toxidromic Approach

3. Look for other illnesses

other than toxicologic

Dr AP Samson Toxidromes
 Toxidromic Approach

Conditions/agents producing metabolic

acidosis or elevated anion gap:
•M Methanol •A Aminoglycosides
•E Ethylene glycol •C Cyanide, CO
•T Toluene, theophylline •I Isoniazid, iron
•A Alcoholic ketoacidosis •D Diabetic ketoacidosis
•L Lactic acidosis

•G Grand mal seizures

•A Aspirin (salicylates)
•P Paraldehyde, Phenformin
Dr AP Samson Toxidromes
 The toxidromic approach
is a helpful tool in identifying an
unknown toxicant.

However, it is not the only

tool.

Dr AP Samson Toxidromes