**6. Toxidromes**

Management of intoxicated patients has a unique approach because of the challenge in diagnosis and treatment of overdose cases. This chapter is focusing on general approaches for intoxicated patients and initial management and on how the history and physical examinations could help physicians to have what drug have been abused as well as review the mechanism of action, physical finding and treatment of the most common drugs-causing toxicity in

Approach for the poisoned patients in emergency includes: resuscitation, history, physical

The initial priorities for a poisoned patient presented emergency department are: securing the air-way and breathing and stabilizing the circulation. Inadequate ventilation may need intubation and mechanical ventilation. First-line treatment of hypotension is IV fluid bolus (10–20 mL/kg), if hypotension is not responding to fluid, it may be necessary to add specific antidote. If the patient presented with signs of opioid over dose (low Glasgow coma scale-GCS respiratory depression, meiosis), give him naloxone (0.1–2.0 mg I.V), check blood sugar

History is very important and can be obtained from the patient, and in case the patient is comatose or cannot give his history, we may take collateral information from family, friends or medical records looking for past psychiatry illness, previous history of suicide or drugs abuse, chronic medication… History must include time, route of entry, quantity, intentional or accidental exposure, availability of drugs at home and if any member of the family has chronic diseases (hypertension, diabetic etc…), missing tablets or any empty pill bottles or

Physical examination of poisoned patients may give clues regarding the substance which has been abused and toxidromes. Physical examination includes: general appearance, mental status (agitated or confused), Skin (cyanosis, flashing, physical signs of intravenous drugs abuse (track marks), eyes: (pupil size reactivity lacrimation and nystagmus), odour (garlic, bitter almonds, glue, alcohol etc.…), Oropharynx hyper salivation or dryness, chest: breath sound, bronchorrhea, wheezing, heart rate, rhythm regularity), abdomen(bowel sound, tenderness, and rigidity), limbs(tremors and fasciculation), patient's clothing (looking for any medications, illegal drugs) [3].

**2. General approach to toxicological cases in emergency medicine**

addition to the drugs with high mortality morbidity rates.

and treat hypoglycaemia with 50% 50 mL dextrose [3].

other material was found around him [4].

**5. Physical examination**

examination and management.

250 Essentials of Accident and Emergency Medicine

**3. Resuscitation**

**4. History**

The term toxidrome was coined in 1970 by Mofenson and Greensher. Toxidromes are group of abnormal physical examination and abnormal vital signs known to present with specific group of medications or substances. Most common toxidromes are Cholinergic, Anticholinergic, Sympathomimetic, opioids, and serotonin syndrome [4, 5].

#### **6.1. Cholinergics**

Patients with cholinergic toxidrome present with wet manifestation. SLUDGE+3 killer B's"or DUMBELLS are simple mnemonics for the common clinical symptoms.

"SLUDGE": Salivation, Lacrimation, Urination, Defecation, GI cramping, Emesis + "Killer B's": Bronchorrhea, Bradycardia, and Bronchospasm.

"DUMBELLS": Diarrhoea, Urination, Miosis (small pupils), Bradycardia, Emesis, Lacrimation, Lethargy, and Salivation.

Most common Causes: Organophosphate pesticides, Carbamates, Same type Mushrooms and Sarin (warfare agent) [4].

#### **6.2. Anticholinergics**

Patients with Anticholinergic toxidrome with dry manifestation, delirium, tachycardia, dry flushed skin, dilated pupils, clonus, elevated temperature, decreased bowl sounds, urinary retention. Simple mnemonics: "Hot as a Hare, Mad as a Hatter, Red as a Beet, Dry as a Bone, Blind as a Bat".

Most common Causes: Antihistamines, antiparkinsonians, atropine, scopolamine, amantadine, antipsychotics, antidepressants, muscle relaxants and plants (Jimson weed) [4].

#### **6.3. Sympathomimetics**

Patient present with CNS stimulation and psychomotor agitation, elevated blood pressure, tachycardia, dilated pupils, hyperthermia, diaphoresis and seizure in severe cases.

Most common causes: cocaine, amphetamine.

#### **6.4. Opioids**

Most common clinical presentation of opioids toxidrome are: coma, respiratory depression and meiosis, hypotension, hypothermia, bradycardia and seizure may occur in propoxyphene overdose, but small pupils not always present may present with normal size pupils such in meperidine and, propoxyphene toxicities [4].

#### **6.5. Serotonin syndrome**

Patient present with altered mental status, hypertensive, and tachycardia, Myoclonus hyperreflexia, hyperthermia and increase muscles rigidity. Most common causes: SSRI interaction or overdose [4].
