Introduction to

toxicology

Team Leaders

Khalid Aleedan & Aseel Badukhon

Done by

Shrooq Alsomali Allulu Alsulayhim

Nawaf Alkhudhayri Weam Babaier
Mohammed Alyousef

Revised by: Yara & Basel

 Ob e t
1 Definition and Terminology

2 Classification of Toxic agents

3 Assessment [History, Examination, Investigation]

4 Management

5 Disposition

6 Poison center No.

This lecture is extremely

important! It sums up all
lectures of the course. It is
essential to understand and
study this lecture first!!

Notes Extra Book Important Golden notes

 { In od on
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Definition of
Toxicology:

A science that deals with the adverse effects of chemicals on living organisms
and assesses the probability of their occurrence.

Why people get

toxic?

1
common when doctors
write the prescription by
Intentional i.e. Wrong dose (i.e.
handwriting, so instead of
writing 10 units they
suicide Insulin1) write 10 U and the U look
like 0, so the nurse give
100 units

Symptoms control Exposure i.e.

3
commonly used by
farmers as pesticide
(i.e. paracetamol radiation, or used to treat lice
for pain2) organophosphate3 in young girls

2
common seen with toothache,
the patient may take 10 tablets
“depends on age; go back to APAP
lecture”and come to ER with liver
problems
Bite i.e. snake bite

What are the routes

of exposure?
● Inhalation (i.e. Nitrous oxide, CO) trick in the MCQs (in
the question they always say: 3 people were in campus or picnic
all of them have headache, nausea, irritability. What is your
diagnosis? CO poison)
● Skin or eye absorption (i.e. organophosphate)
● Ingestion : major one (i.e. paracetamol….etc)
● Injection (i.e. Opioids, insulin)

CO commonly seen in fire or from vehicle exhaust. We commonly see it during summer bc of firewood. The
problem of CO that it is odorless and painless, so people die without noticing or suffocation. CO can mimic
stroke, how to differentiate? Once you give O2 in CO poison they improve unlike stroke
 { As e s t
{
History:

● May be unclear Because if they are addicted or had used the drug for suicide . they won’t tell you that. Also, they
could be unconscious hence won’t know what happened (Someone put something in their food or drink)
● Substance abuse!, if the patient was comatosed, we ask relatives or EMS if they saw any tablet or bottles or gases
in the seen
● Dose (hard to estimate cuz they gonna tell you I took the whole bottle but they don’t know how many pills was in
the bottle)
● Route of exposure you know by seeing black discoloration of nose or injection marks
● Collateral Hx (i.e. family, friends, medical records)
● Prehospital medical staff (i..e empty containers)

● Other (i..e hobbies like farming which can hint towards a snake bite
“organophosphate” or ‫ ﻣﺧﯾﻣﺎت‬which point towards CO poisoning , occupation,
suicide note, change in behaviour recently which can point out to suicide)

Examination:

Organ system Example of finding

General appearance Malnourished (IV drug user, HIV infection)

IV users: dehydrated, cachexic, poor hygiene, poor selfcare

Miosis* (So if you find in the question miosis this means Opioids or organophosphate
CNS poison) Nystagmus**/ataxia*** (ethanol)
*the pupil in constricted (less than 3 mm) **rapid movement of the iris ***unsteady gait

Murmur (Endocarditis/IV drug user) letting bacteria in with injection. Usually the
CVS question is: fit and healthy patient develop new onset of murmur and you find fresh mark
on the vein

Respiratory system Bronchorrhea/crepitations/hypoxia ( Organophosphate)

Oral cavity burns ( corrosive ingestion**** , hyper salivation cholinergic toxidrome)

GIT ‫ ﻟﻣن ﻧﺣطﮫ ﻓﻲ ﻛﺎس ﯾﻛون ﻟوﻧﮫ أﺻﻔر ﻓﺎﻷطﻔﺎل ﯾﻧﺟذﺑون ﻟﮫ وﯾﺷرﺑوﻧﮫ‬،‫****ﻣﺛل اﻟﻛﻠورﻛس‬

Urinary retention ( anticholinergic toxicity)

Urology

Tremor (Lithium, seen in bipolar patient) Lead pipe rigidity***** (NMS)

Peripheral nerves clonus/hyperreflexia (serotonin toxicity)
*****if you ask the patient to flex, they will resist resist then they will flex

Bruising (anticoagulant) flush, dry skin(anticholinergic toxicity) warm, moist

Dermal skin(sympathomimetic toxicity)

DO ’T O G !
Examine skin folds, clothes and bags for retained tablets or substances
usually drug users hide their drugs under their skin fold. Couples of days ago
we found amphetamin hidden under the patient’s scrotum :) so look carefully
 {
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Tox me
All toxidrome are important!

Definition of
Toxidrome:

Cluster of symptoms and signs enabling the identification of potential toxins

when a clear history is unavailable.
(gathering the symptoms and signs and getting an idea about what the
patient used.)

Anticholinergic (Antimuscarinic)
e.g. Atropine

Clinical features (NO

Agent Potential interventions
WATER)

- Altered mental status - Scopolamine - Physostigmine

- Mydriasis - TCA - Benzodiazepine for
- Dry flushed skin - Olanzapine sedation (MCQs)
- Urinary retention - Antihistamine - Cooling
- Decreased bowel sounds - Diphenhydramine - Supportive management
- Hyperthermia (cause of like IV fluid
death)
- Dry mucus membrane
- Other:
-Seizure
-Rhabdomyolysis
-Arrhythmia

Make it more fun to

memorize..! “Mad H te ”
“Bli s a” Con d
“Red e t”
Flu d n
“Hot es t”
“Dr a b e” Dil Pup Hy e t m a
Dr o t (My i s )
Uri y en
Sha g, g a b
Ab e t l in b e j s
so s Tac c a
 {
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Tox me
Cholinergic (Muscarinic)

Clinical features (TOO MUCH WATER) Agent Potential interventions

-Muscarinic effect: - Organophosphate - Airway protection +

-Salivation insecticides ventilation
-Lacrimation - Carbamate insecticides - Atropine the antidote
-Diaphoresis - Pralidoxime
-Nausea
-Vomiting
-Urination
-Defecation
-Bronchorrhea
- Nicotine effect
-Muscle fasciculations-
Weakness
- Other
-Bradycardia
-Miosis/Mydriasis
- Cause of Death -> respiratory
arrest from muscle paralysis

Swe g
Make it more fun to Pin t u l
(mi )
(Di p es )

memorize..!
Cr i g (Lac ti )
Fro n t e t
(Sal i n & Run g e (Rhi r a)
Bro h h a)
Vom g (em )

Bra c a

Uri on Di r a
 {
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Tox me
Sympathomimetics

Clinical features Agent Potential interventions

- Psychomotor agitation -Amphetamine -Cooling

-Mydriasis (very common in -Sedation with
-Diaphoresis our society) benzodiazepine
-Tachycardia -Cocaine -Hydration
-Hypertension
-Hyperthermia
-Others:
-Seizure
-Rhabdomyolysis
-MI
- Death -> seizure, cardiac arrest, hyperthermia

*NB/ very close to anticholinergics but the

difference in diaphoresis (sweating) important
for MCQs

Opioids

Clinical features Agent Potential interventions

- CNS depression - Heroin - Naloxone

- Respiratory depression - Morphine - +\- airway support and
- Miosis - Oxycodone ventilation
- Others:
-Hypothermia
-Bradycardia Needs observation
- Death from respiratory depression

Sedative-Hypnotic

Clinical features Agent Potential interventions

- Depressed LOC (Level Of - Benzodiazepines along - Ventilatory support (give

Consciousness) with sympathomimetics them O2, if it didn’t work
- Ataxia sometimes intubate them)
- Slurred speech - Barbiturate
- Respiratory depression
- Bradycardia
*NB/ very close to opioids but the
difference is NO Miosis ‫ﯾﻘوﻟﻛم اﻟدﻛﺗور ھﻧﺎ ﻧﻠﻌب ﻓﻲ‬
‫ اﻻم ﺳﻲ ﻛوﯾز ﻓرﻛزوا ﷲ ﯾرﺿﻰ ﻋﻠﯾﻛم‬:)
 {
{
Tox me
Hallucinogenic Rape drugs

Clinical features Agent Potential interventions

- Hallucinations - Phencyclidine -Supportive

- Dysphoria - Lysergic acid diethylamide
- Anxiety (party drugs)
- Hyperthermia - Psilocybin
- Mydriasis - Mescaline
- Nausea
- +\- sympathomimetics

Other Toxidromes

Toxidrome Examination finding

altered mental status, diaphoresis, tachycardia, HT

You should give them dextrose if you are in hospital or in ambulans.
Hypoglycemic (i.e.insulin) If you are at home give sugar or honey under the tongue or on the
buccal region)
(These are not typical toxins)

altered mental status, hyperreflexia,

Serotonin (i.e. SSRIs) hypertonia(LL>UL), clonus, tachycardia

Neuroleptic Malignant severe muscle rigidity, hyperpyrexia (fever) , altered

(i.e.antipsychotics) mental status (Serotonin and neuroleptic are similar but you can
differentiate by fever which occurs in neuroleptic)

Extrapyramidal Dystonia, torticollis, muscle rigidity

(i.e.haloperidol)

Ethanol CNS depression, ataxia, dysarthria, smell of ethanol

AMS, Resp Alkalosis, Metabolic Acidosis, Tinnitus,

Salicylate (i.e. Aspirin) know Tachypnoea, Tachycardia, diaphoresis, nausea
the findings vomiting
 { Di g ti
Step 3 in assessing
after history and
{
examination

te s
These tests are:

Bedside:
● Blood Glucose level : hypoglycemia You should give
them dextrose if you are in hospital or in ambulans. If you are at
home give sugar or honey under the tongue or on the buccal region)
● ECG: Arrhythmias anticholinergic drugs can cause them
● VBG: i.e. metabolic acidosis —> paracetamol

y:
Laborator
List of drug
concentrations that may
● Blood / urine drug level(actually it won’t point out which
help in assessment! exact drug the patient use, so it kind of pointless. except
paracetamol but I should wait 4 hours from the ingestion time to
see the result)

es:
Electrolyt
● K level :
i.e. hyperkalemia in digoxin overdose

tion
Liver Func
Tests:
● Elevated liver enzymes in Paracetamol
toxicity Ethanol and amphetamine level

Limitations of Drug
screening assays:

1 Nonspecific 2 Time Frame 4 Cross-reactivity

Drugs may be detected days Carbamazepine, cyproheptadine and
Most tests use
to weeks after exposure. A chlorpromazine test positive for
enzyme-immunoassays that only
positive test may not account tricyclic antidepressants.
detect typical drugs within class:
for current clinical findings Selegiline, methylphenidate and
opioids, amphetamines,
pseudoephedrine test positive for
benzodiazepines, cannabinoids,
amphetamines.
cocaine, barbiturates.
Amphetamine screens don’t detect
methylenedioxy-methamphetamine 3 Noninclusive
5 Sampling error
.
Opioid screens don’t detect A negative drug screen
meperidine. doesn’t exclude a rare Assay may be negative if
Benzodiazepines screens don’t exposure. dilute urine is tested.
detect flunitrazepam.
 { Man en
Step 4
{
When a patient comes with a toxidrome,
these steps must be followed accordingly:

(after assessment and running tests)

Resuscitation
1

2 Decontamination

Disposition
3

Resuscitation:

Airway (is the

patient breath
or not) - Intubation: if compromised (the patient doesn’t speak in normal way or the
patient is choking)

Breathing
(equal breath - O2 administration, if hypoxic (i.e. oxygen saturation <94%)
at two side) - Mechanical ventilation if intubated

Hypotension:
- IV fluid like normal saline or blood ( 10-20ml /Kg ) , avoid excess
Circulation
(normal vital fluid administration
signs or not) - specific antidote (Next slide to check that very good list of antidotes!)
- inotropic support ‘vasopressin’ ( i.e.Adrenaline infusion)

Aim : systolic BP > 90mmHg or MAP (Mean Arterial Pressure) >65 mmHg

A B c
“Rem r e AB ru re c a n”
 { Man en
This table is very
important through all
toxicology lectures,
memorize the drugs in
{
your lectures!
At Least 3 will come in
MCQs

Poison Antidote
Acetaminophen | Anticholinergic N-acetylcysteine | Physostigmine

Anticoagulants Vitamin K, FFP

Aspirin Sodium Bicarbonate “NaHCO3”

Beta blockers Glucagon, insulin

Benzodiazepines Flumazenil

Ca channel blockers Ca, glucagon, insulin

Carbon monoxide “CO” Oxygen

Cholinergics Atropine

Cyanide Hydroxycobalamin,amyl nitrite, sodium thiosulfate

Digoxin | Heparin Digoxin FAB | Protamine

Hydrofluoric acid Calcium gluconate

Insulin | Iron Glucose | Desferoxamine

Isoniazid | Methanol4 Pyridoxine | Ethanol4

Ethylene Glycol Fomepizole, ethanol

Methemoglobin Methylene blue

Opioids Naloxone

Serotonin repute inhibitors Cyproheptadine

Sulfonylurea Octreotide, glucose

Tricyclic antidepressants Sodium bicarbonate

Heavy metals:
Dimercaprol
-Arsenic
EDTA
-Copper
Penicillamine
-Lead
Succimer (DMSA)
-Mercury

4
Bc they believe ethanol is safe, but methanol, isobornyl alcohol, ethylene glycol are harmful
 { Man en
{
Resuscitation:

Some specific presentations:

- BGL (blood glucose level) : < 4 mmol

Hypoglycemia
- give IV dextrose (Glucose)

- Antiarrhythmic drugs are not first line treatment in toxin

induced arrhythmias
Cardiac Arrhythmias - Treatment:
- O2 sat
- antidote (i.e. digoxin Fab in digoxin overdose)
NO Beta Blockers!

- Treatment
1st : IV benzodiazepine ( except in Isoniazid toxicity —>
Pyridoxine)
Seizure
2nd: Barbiturates
- Treat hypoglycemia and hyponatremia
- No rule for Phenytoin in toxin induced seizure

- 1st line treatment: Benzodiazepine

Agitation
- 2nd line treatment: Antipsychotic agents

Hyperthermia and - Core temperature > 39* —> aggressive cooling

hypothermia - Core temperature <32* —> aggressive rewarming

Here we either clean your gut (GIT decontamination) or

Decontamination: your blood (enhanced elimination)!

1-GIT Decontamination: 2-Enhanced Elimination:

-Activated Charcoal -Multiple dose activated charcoal
-Whole Bowel irrigation prior to -Urine alkalinisation
colonoscopy. -Extracorporeal technique of
-Gastric lavage very bad elimination:(harm-dialysis and
-Induced Emesis (Syrup or hemofiltration ,charcoal
Ipecac) very bad hemoperfusion)
 { Man
{
en
GIT
Decontamination:

:) ‫ﺗﺄﻛل اﻟﻣرﯾض ﻓﺣم‬ 1-Activated charcoal

(single dose)
Charcoal will bind to the drug and and excrete it outside the body

Indications Contraindications Complication Technique

-Preferred method -Incomplete initial -Vomiting 30% -Dose:

<1 hour from ingestion resuscitation -Messy -50 gm for
-Non toxic ingestion -Aspiration adult
-Charcoal sensitive -Direct
-Subtonic dose -1 gm/kg for
substances (MCQs): administration into
1- Paracetamol -Risk assessment -> good lung if NG tube children
2- Benzodiazepines outcome with supportive placed in lung -Mix with water
3- Barbiturates care and antidote -Impaired absorption -Self administration
4- TCA -Risk assessment -> of subsequent oral if GCS 15
5- Phenothiazines potential for seizure of antidote, therapeutic -Via OG / NG tube if
6- Most agent
decrease LOC intubated (first
anticonvulsants -Corneal abrasion
-Decreased LOC, seizure confirm tube position
7- Aspirin -Staff distraction
8- Theophylline (unless intubated) from resuscitation with chest X-ray)
9- Digoxin -Charcoal resistance and supportive
10-Dextropropoxyphen agent (see below) priorities
e -Corrosive ingestion *No difference
11- Amphetamines between mixing AC
12- Quinine with water or with
13- Morphine other (sorbitol)
*Ileus is not a
14- Ciclosporin contraindication
15- Most NSAIDs
16- Beta blockers

Charcoal resistance substances:

(Doesn’t bind to charcoal)

Hydrocarbons and Ethanol, Isopropyl Ethylene glycol,

alcohol alcohol Methanol

Lead, Arsenic,
Metals Lithium, Iron, K
Mercury

Corrosive Acid Alkalis

 { Man en
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2-Whole Bowel Irrigation
(WBI)

Indications Contraindications Complication Technique

-Iron overdose >60 mg/kg -Risk assessment-> good -Nausea / vomiting -Polyethylene glycol
-Lead ingestion outcome with supportive - Abdominal bloating electrolytes solution
-Arsenic ingestion care and antidote -Non anion gap (PEG-ELS) (Remember
-Body packers (‫اﻟﻧﺎس اﻟﻠﻲ‬ -Risk assessment -> metabolic acidosis GNT block!)
‫ﯾﮭرﺑون اﻟﻣﺧدرات وﯾﺧﺑوﻧﮭﺎ ﻓﻲ‬ potential for seizure or -Pulmonary aspiration -Single nurse assigned
‫)ﺟﺳﻣﮭم‬ decrease LOC -Staff distraction -Enough supply of
-Slow release preparation: -Uncooperative patient from resuscitation PEG-ELS
1-Lithium -Inability to place NG and supportive care -NG tube inserted and
2-Verapamil/diltiazem tube priorities confirmed
3-Potassium formulations - Uncontrolled vomiting -Delayed retrial to a -AC charcoal
- Ileus* hospital offering -Administer PEG:
- Intestinal obstruction definitive care 1-Adult 2L/hr
-Intubated and 2-Child 25 ml/kg/hr
ventilated patient No doses required -Give metoclopramide ->
(relative) decrease vomiting and
enhance motility
*While in activated -Explosive diarrhoea
charcoal was NOT a -Continue irrigation until
contraindication it clear
-Stop if abdominal
distention or bowel
sound lost

This method is not used

anymore; not important, 3-Gastric Lavage
skip it (: Just know the
name.

Indications Contraindications Complication Technique

-Rare in ED -Incomplete initial -Pulmonary aspiration -Resuscitation area

-Serious resuscitation -Hypoxia -GCS 15 / intubated pt
poisonings <1hr -Risk assessment-> good -Laryngospasm -Left decubitus position, head down
- Other methods outcome with supportive -Mechanical injury to 20
are unavailable care and antidote GIT -Pass gastric lavage tube (36-40 G)
-Mercury -Decreased LOC -Water intoxication (OG route)
ingestion -Risk assessment -> (children) -Confirm tube position (asprination
- Arsenic potential for decreased -Hypothermia and auscultation)
ingestion LOC during the -Staff distraction form -Administr 200 ml Aliquot of warm
procedure resuscitation and tab water or NS
-Small children supportive priorities - Drain the fluid into dependent
-Corrosive ingestion bucket
-Hydrocarbon ingestions -Repeat until it’s clear
-Give AC 50 G via the lavage tube
once lavage is completed
 { Man en
{

This method is not 4-Induced Emesis (Syrup

used anymore; not
important, skip it (: of Ipecac)
Just know the name

Indications Contraindications Complication Technique

-Limited -Non toxic ingestions -Prolonged vomiting > -Children >> 15 ml

-Charcoal resistant poison -Sub toxic doses 1 hour in 10%-20% -Adult >> 15-30 ml
-Serious risk of toxicities -Seizures -Diarrhea 20% -With glass of water
- < 1 hour after ingestion -Decreased LOC -Lethargy 10% -Usually vomit after 18
-Large fragments in -Risk assessment >> -Pulmonary aspiration min
stomach (WBI is better) Potential for seizure / if (Seizure / -Repeat the dose if no
-Fe (Iron) Decreased LOC within decreased LOC) vomit after 30 min
-Sustained release lithium the next few hours -Mallory weiss tear
-Enteric coated tab -Activated charcoal -Pneumomediastinum
-Poisonous mushrooms available within 1 hour -Gastric perforation
and know to bind to the
substance
-Infant < 12 months
-Corrosive ingestion
-Hydrocarbon ingestion
 { Man en
{
Enhanced Elimination:
“Be careful, we
have single dose
and multiple doses
1-Multiple Doses of AC of AC!”

Indications Contraindications Complication Technique

-Carbamazepine coma -Decreased LOC -Vomiting 30% -Give the atoll dose:
(most common -Anticipate decrease -Pulmonary aspiration -50 g for adult
indication) of LOC -Constipation -1 gm/kg for children
-Phenobarbital coma -Bowel obstruction -Bowel obstruction -Repeat doses of:
-Dapsone overdose -> -Bowel perforation -25 gm for adult
methemoglobinemia -Corneal abrasion - 0.5 g/kg for children
-Quinine. Overdose -Staff distraction -every 2 hours
-Theophylline overdose from resuscitation -route:
-Phenytoin and supportive care -oral if GCS 15
-NG/OG tube after position
confirmed by chest X-ray
-Check bowel sound before
each dose;
-If no bowel sound stop doses
-Reconsider indication and
endpoints every 6 hours
-Very rare therapy continue >6
hours

2-Urinary Alkalinisation

Indications Contraindications Complication Technique

-Salicylate overdose -Fluid overload -Alkalemia -Sodium bicarbonate

-Phenobarbital coma -Hypokalaemia -1-2 mmol/kg IV bolus
(not first line) -Hypocalcaemia -Infusion @ 250 ml/hr
-Cyanide -Volume overload - 100 mmol NaHCO3 in 1000 ml
-Isoniazid 5% dextrose
-Toxic alcohol
Mechanism -Add 20 mol of KCL to the
-Tricyclic infusion to maintain the
antidepressants Make urine PH alkaline -> normokalaemia
-Propranolol ionisation of highly acidic -Follow serum HCO3 and K
-Flecainide drug -> decrease renal every 4 hr
-Quinidine absorption and increase -Aim urine PH>7.5
-Methotrexate renal excretion. Give them -Continue till the lab and clinical
sodium bicarbonate to make evidence of toxicity is resolved
them urinate
 { Man en
{
3-Extracorporeal
Technique of elimination

Hemodialysis Hemoperfusion

Movement of toxin from

Movement of solute down blood, plasma or plasma
a concentration gradient protein into a bed of
across a semipermeable activated charcoal (or other
membrane VS adsorbent) (It uses dialysis
but the filter is different
Contraindicated in
hemodynamic instability, poor here)
vascular access and (Blood is taken from a vein or
significant coagulopathy artery then returned via
VEIN)

Indications Contraindications Complications Technique

-Severe life -Hemodynamic -Hypotension -Invasive

threatening (most common) -Special; staff
-Deterioration
instability
despite full -Poor vascular -Bleeding from -Special
supportive care vascular access equipment
access
-Carbamazepine -Air emboli -Monitoring
-K overdose -Significant -Blood loss
-Sodium Valproate coagulopathy -Systemic
-Metformin
heparinisation
-Phenobarbitone
-Chronic lithium -Thrombocytope
-Salicylate nia
-Toxic alcohol -Neutropenia
-Methanol, Ethylene
Glycol
-Theophylline

Disposition:

Poison Center
If asymptomatic for 6 hours in ED number:
—> discharge, otherwise admission 0112324189/0112
to hospital is required 324180
Be safe (:
 { How c o
{
k o l is!
1-Which of the following toxin-antidote combination is the most
appropriate?
A) Iron - Insulin
B) TCA - Sodium bicarbonate
C) Aspirin - Glucagon
D) Lead - H2O2

2-Ethanol resists which of the following?

A) Charcoal
B) Lead
C) PEG
D) Methanol

3-In hemoperfusion, blood is returned after filtering to patient via

artery.
A) True
B) False

4-When should you stop the administration of multiple doses of AC?

A) When you are able to hear 3 bowel sounds per minute
B) When you hear none
C) When you hear 2 bowel sounds per minute
D) You should never consider this until patient improves

5-Anticholinergic and stimulants are similar but

A) Anticholinergic causes sweating while stimulant doesn’t
B) Anticholinergic causes miosis while stimulant causes mydriasis
C) Anticholinergic doesn’t cause diaphoresis while stimulant causes it
D) None of the above

1-B
2-A
3-B
4-B
5-C
 { Sum y
{
Introduction

Definition of Toxicology Why people get toxic? What are the routes of exposure?

● Intentional ● Inhalation
A science that deals with the
● Wrong dose ● Skin or eye absorption
adverse effects of chemicals on ● Symptoms control
living organisms and assesses the ● Ingestion
● Exposure
probability of their occurrence. ● Injection
● Bite

Imp
rtan o
Toxidrome How to differentiate ?! t!
Anticholinergics and sympathomimetics have same clinical
features But anticholinergics don't cause diaphoresis
● Anticholinergic (antimuscarinic)
(sweating), while sympathomimetics cause diaphoresis.
● Cholinergic (muscarinic)
● Sympathomimetics
The difference between Opioid and Sedative-hypnotic is
● Opioids
that the opioid affects the pupil, while the
● Sedative-hypnotic
Sedative-hypnotic doesn't affect the pupil.
● Hallucinogenic

When we have a toxidrome, we need an antidote! Remember to

memorize them all!
Diagnostic tests

These tests are: Limitations of drug screening assays

● Nonspecific
● Bedside
● Time frame
● Laboratory
● Non inclusive
● Electrolytes
● Cross-reactivity
● Liver Function Tests
● Sampling error

If asymptomatic for 6 hours in ED —> discharge,

Management otherwise admission to hospital is required

Resuscitation GIT decontamination Enhanced elimination

● Multiple doses of AC:

● Activated Charcoal (single
● Airway ● Urinary alkalinisation
dose)
● Breathing ● Extracorporeal technique
● whole bowel irrigation
● Circulation of elimination
● Gastric Lavage
 Thank you and good luck!

Very Toxic but you are

gonna do it!
A+ is s (:

● Email us at:

436to lo @g a .co

How l o t k e v o ? We r a n or fe c!

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