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  • 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.

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Most Common Toxic Syndromes
Organophosphates, nerve agentsCholinergic
  • 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.

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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

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  • 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)
Organophosphates/carbamatePralidoxime + atropine
Ethylene glycol/methanolFomepizole
Calcium blockersCalcium

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