Toxidromes and Drug Ingestions

Toxidromes are combinations of clinical signs that can indicate the type of drug ingestion a patient has experienced. Common toxidromes include anticholinergic, cholinergic, sympathomimetic, sedative, hallucinogenic, and serotonergic presentations. This guide explores the key features, causes, and management of anticholinergic and cholinergic toxidromes, providing valuable insights for healthcare professionals managing drug ingestions.

• Toxidromes
• Drug Ingestions
• Anticholinergic
• Cholinergic
• Clinical Signs

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1. Toxidromes and Drug Ingestions

2. Toxidromes What is a Toxidrome? A constellation of clinical signs that may suggest a particular type of ingestion Toxidromes may indicate what type of drugs a patient has taken if they are unable or unwilling to tell you

3. Toxidromes The most common toxidromes seen are: Anticholingeric Cholinergic Sympathomimetic Sedative Hallucinogenic Serotonergic

4. Anticholinergic Toxidromes

5. Anticholinergic Toxidrome Due to drugs that block muscarinic and nicotine acetylcholine receptor Antihistamines (1stgeneration) Tricyclic antidepressants Antitussives (cough mixtures) Antipsychotics Anticonvulsants Antimuscularinic drugs Atropine Scopolamine Ipatroprium bromide Plants Mushrooms Datura

6. Anticholinergic Toxidrome The anticholinergic toxidrome consists of: Delirium + peripheral antimuscarinic effects Mad as a hatter Confusion/hallucinations/seizure/coma Red as a beet Flushed skin Blind as a bat Mydriasis Hot as a hare Hyperthermia Dry as a bone Dry skin, urinary retention, ileus

7. Cholinergic Toxidromes

8. Cholinergic Toxidrome Due to drugs that activate acetylcholine receptor ie the opposite of anticholinegric toxidromes

9. Cholinergic Toxidrome Caused by: Organophosphate insecticides Carbamate insecticides Chemical warfare agents eg Ricin, Tabun, Soman, VX Alzheimer's medication eg donepezil Agents used for myasthenia gravis Neostigmin Edrophonium Pilocarpine Phyostigmine

10. Cholinergic Toxidrome The cholinergic toxidrome = DUMBELS : D Diaphoresis Diarrhoea (and abdo cramps) U urination M Miosis (or mydriasis) B Bronchospasm Bronchorrhoea Bradycardia E Emesis L Lacrimation S Salivation

11. Sympathomimetic Toxidromes

12. Sympathomimetic Toxidrome Act via stimulation of sympathetic nervous system Toxidrome everything stimulated Hypertension Tachycardia Tachypnoea Hyperthermia Agitation Dilated pupils (usually) Diaphoresis/flushing c.f: anticholinergic dry

13. Sympathomimetic Toxidrome In New Zealand the most commonly seen sympathomimetic ingestion is methamphetamine Can also be seen with Alpha receptor agonists Phenylephrine eg OTC cold preparations eg - coldrex Beta receptor agonist Salbutamol Theophylline Caffeine Alpha and beta agonists Amphetamine Cocaine Pseudo/ephedrine MDMA (ecstasy)

14. Sedative or Hypnotic Toxidromes

15. Sedative or Hypnotic Toxidrome Caused by any medication that causes CNS depression, such as: Benzodiazepines Barbiturates Alcohols Opioids Anticonvulsants Antipsychotics

16. Sedative or Hypnotic Toxidrome Toxidrome Decreased Level of consciousness Hypoventilation Hypotension Bradycardia Opioids + barbiturates also cause Miosis Hypothermia

17. Hallucinogenic Toxidromes

18. Hallucinogenic Toxidrome As it sounds, this is caused by drugs and agents that cause hallucinations Amphetamine Cannaboids Cocaine LSD PCP Magic mushrooms (Psilocybin spp.)

19. Hallucinogenic Toxidrome Primarily presents with hallucination Also can present with: Frank psychosis Panic attacks and anxiety Sympathomimetic symptoms esp. tachycardia, hypertension and fever

20. Serotonergic Toxidromes

21. Serotonergic Toxidrome A collection of signs and symptoms produced by excess serotonin in the central, peripheral and autonomic nervous systems

22. Serotonergic Toxidrome Multiple medications can cause serotonergic toxidrome (or serotonin syndrome) Most commonly occurs when 2 medications which affect either serotonin reuptake or metabolism are given, but can also occur with a single agent

23. Serotonergic Toxidrome Associated with: Selective serotonin reuptake inhibitors (SSRI -antidepressants) Eg paroxtetine, fluoxetine Serotonin noradrenalin reuptake inhibitors (SNRI antidressants) Eg venlafaxine, citaloprma Tricyclic antidepressants Monoamine oxidase iunhibitors (Block serotonin break down used as antidepressants) Eg moclobmide Analgesic Eg pethidine, tramadol, fentanyl Antiemetics Eg metoclopramide, ondansteron Anticonvulsants Eg valproaic acid Dietary supplements Eg St johns wort, ginseng

24. Serotonergic Toxidrome Produces wide variety of signs and symptoms due to CNS, peripheral and autonomic dysfunction Most commonly produces Tremor Hyperreflexia and muscle rigidity esp in the legs Clonus Fever Tachycardia and hypertension