Skip to Main Content

++

  • Airway with specific care on cervical spine immobilization (unless trauma has been excluded)
  • Breathing, oxygenation, and need for intubation
  • Circulation—fluid resuscitation and continuous cardiac monitoring
  • Decontamination of GI—only if ingestion within 1 hour
  • Elimination of toxin—antidotes, charcoal hemoperfusion, hemodialysis
  • History—past medical and psychiatric history, prescription drugs, empty bottles found and pill count, time of ingestion
  • Examination—a quick, but detailed exam focusing at identifying a toxidrome to narrow on the toxin ingested (multiple drug ingestion common)

++

Always check pupils, temperature, and GCS along with vitals to identify toxic syndrome.

++
Table Graphic Jump Location
Favorite Table | Download (.pdf) | Print
Most Common Toxic Syndromes
DrugsSyndromeSymptomsTreatment
Organophosphates, nerve agentsCholinergic
  • DUMBELS1
  • Constricted pupils
Antidote: pralidoxime, atropine
Atropine, benztropine, tricyclic antidepressants, antihistaminesAnticholinergicFlushed dry skin, fever, dilated pupils, psychosis, seizures, HTN, tachycardia, urinary retention, ileus
  • Antidote: physostigmine (do not use if EKG changes or seizures occur)
  • Seizures: benzodiazepines
Cocaine, MDMA (Ecstasy), phencyclidine (PCP), amphetamines, caffeine, decongestants (ephedrine), theophyllineSympathomimetic (adrenergic)Fever, HTN, tachycardia, dilated pupils, seizures, diaphoresis
  • Sedation: benzodiazepines
  • HTN control: labetalol (avoid beta-blockers)
Morphine, fentanyl, Percocet, heroin, methadoneOpiateHypothermia, constricted pupils, bradycardia, hypotension, respiratory and CNS depressionAntidote: naloxone
Benzodiazepines, barbiturates, Ambien, chloral hydrate, diphenhydramine, antipsychoticsSedative–hypnoticSlurred speech, altered mental status, respiratory and CNS depression—apnea, hypotension, hypothermia
  • Alkaline diuresis for barbiturates
  • Flumazenil only for acute BZD overdose
  • Hemodialysis

1DUMBELS—diaphoresis/diarrhea, urination, miosis, bronchospasm/bronchorrhea/bradycardia, emesis, lacrimation, salivation.

++
Table Graphic Jump Location
Favorite Table | Download (.pdf) | Print
Hyperthermic Syndromes
Neuroleptic malignant syndrome (NMS)T >40°C, rigidity, delirium, seizures, autonomic instability, elevated CPKOverdose of neuroleptic drugs, metoclopramide, haloperidolTreatment: bromocriptine
Malignant hyperthermia (MH) (see Chapter 223)Hyperthermia, rigidityAnesthetic agents—succinylcholine, halothaneTreatment: dantrolene
Serotonin syndromeIrritability, flushing, tremor, myoclonus, diarrhea, diaphoresisOverdose of SSRI or SSRI with MAO inhibitorTreatment: cyproheptadine, and benzodiazepines if seizure
++

  • Laboratory investigations: CBC, Chem-7, blood glucose, anion gap, osmolar gap, PT/PTT/INR, LFTs, drug levels (acetaminophen, salicylate, digoxin, phenytoin, valproate, phenobarbital, lithium, theophylline as per history; quantitative levels useful for these drugs as they will change management), urine tox screen, alcohol level
  • EKG—rate, rhythm, ORS duration, QTc interval
  • CXR and abdominal x-ray to look for radio-opaque drugs (iron, heavy metals, and enteric-coated drugs) or packets of illicit drugs

++
Table Graphic Jump Location
Favorite Table | Download (.pdf) | Print
Antidotes...
ToxinAntidote
Chloroquine
  • Sodium bicarbonate 1–2 mEq/kg for QRS >120 ms
  • Diazepam 2 mg/kg
Cyanide (sodium nitroprusside drip)
  • Hydroxocobalamin (converts cyanide and forms cynocobalamin)
  • Sodium thiosulfate (enhances conversion to sodium thiocyanite)
  • Sodium nitrite (induces methemoglobinemia)
Oral hypoglycemic medications
  • Dextrose IV (D50 50 mL IV) + glucagon (1–2 mg IV/IM/SQ)
  • Octreotide (2–10 μg/kg IV q12 h), diazoxide (oral)
MethemoglobinemiaMethylene blue (1–2 mg/kg IV over 5 min, q30 min PRN)
AcetaminophenN-Acetylcysteine
Organophosphates/carbamatePralidoxime + atropine
Ethylene glycol/methanolFomepizole
Beta-blockerGlucagon
Calcium blockersCalcium
Benzodiazepines

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.