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Chapter 6: Toxicology

James Dazhe Cao; Janetta L. Iwanicki; Howard Kim; Java Tunson

DIFFERENTIAL DIAGNOSIS BY CHIEF COMPLAINT

Although the poisoned patient may present with varied symptoms and complaints, the chief presenting complaint or symptom may suggest a diagnosis (Table 6.1).

Table 6.1.Primary Considerations for Presenting Chief Complaint in the Poisoned Patient
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Table 6.1. Primary Considerations for Presenting Chief Complaint in the Poisoned Patient
CHIEF COMPLAINT COMMON CAUSES

Coma

Alcohols

Antipsychotics

Antiseizure medications

Carbon monoxide

Cyanide

Muscle relaxants

Opioids

Sedative/hypnotics

Delirium

Anticholinergics/cholinergics

Muscle relaxants

Neuroleptic malignant syndrome

Serotonin syndrome

Sympathomimetics

Withdrawal syndromes

Seizure

Antidepressants (tricyclics, bupropion)

Anticholinergics/cholinergics

Isoniazid

Local anesthetics

Methylxanthines (caffeine, theophylline)

Mushrooms (Gyromitra sp.)

Sympathomimetics

Toxic alcohols

Withdrawal syndromes

Hepatic injury

Acetaminophen

Carbon tetrachloride

Ethanol

Iron

Mushrooms (Amanita phalloides)

Renal injury

Ethylene glycol

Heavy metal salts (mercury)

Mushrooms (Cortinarius orellanus)

Rhabdomyolysis (cocaine, amphetamines)

TOXIDROMES

Recognition of grouped symptoms and findings consistent with a toxidrome (Table 6.2) can guide diagnosis and treatment in the poisoned patient.

Table 6.2.Toxidromes
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Table 6.2. Toxidromes
TOXIDROME COMMON AGENTS PRESENTATION TREATMENT

Anticholinergic

(see also Table 6.7)

Antihistamines Jimsonweed (scopolamine) Deadly nightshade (atropine)

Altered mentation

Dry, flushed skin

Mydriasis

Hyperthermia

Seizures

Tachycardia

Urinary retention

Benzodiazepines

Physostigmine

Cholinergic

(see also Table 6.8)

Organophosphates

Carbamates

Sarin

Altered mentation

Bradycardia

Bronchospasm

↑ Secretions

Miosis

nausea/vomiting, defecation

Seizures

Urination

Atropine 2-PAM (for organophosphates)

Sympathomimetic

(see also Sympathomimetics)

Ephedrine

Ma Huang (Ephedra)

Cocaine

Amphetamines

Agitation

Diaphoresis

Hallucinations

HTN

Hyperthermia

Mydriasis

Muscular rigidity

Tachycardia

Benzodiazepines

Sodium bicarbonate (for wide complex dysrhythmias)

Opioid

(see also Opioids)

Morphine

Heroin

CNS depression

Bradycardia

Hypothermia

Miosis

Respiratory depression

Naloxone

CNS, central nervous depression; HTN, hypertension.

PRINCIPLES OF GASTROINTESTINAL DECONTAMINATION

Gastrointestinal (GI) decontamination refers to therapies that may decrease the amount of poison absorbed from the GI tract. Methods include induced emesis, gastric lavage (GL), activated charcoal (AC), or whole-bowel irrigation (WBI).

Induced Emesis

Induced emesis utilizes syrup of ipecac to induce vomiting, theoretically emptying the stomach, and reducing absorption of an ingested agent. Syrup of ipecac induces vomiting by activation of both local and central emetic receptors.

  • Induced emesis has largely been abandoned in clinical practice.

  • Policy statements released by both the American Academy of Pediatrics and the American Association of Poison Control Centers discourage the use of syrup of ipecac.

Gastric Lavage

Gastric lavage (GL) attempts to directly remove stomach contents by using an orogastric tube.

INDICATIONS

  • Ingestion of a substance with high-toxic potential and:

    • Within 1 hour of ingestion.

    • Ingested substance is not bound by AC or has no effective antidote.

    • Potential benefits outweigh risks.

      ...

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