Toxidrome

Drug Example

Signs & Symptoms

Stimulant

Cocaine, Amphetamine

Restless

Insomnia Tachycardia

hyper-hypotension, Paranoia Convulsions Cardiac Arrest

Narcotic, Opiate, Opioid

Heroin, Morphine Tramadol

Hypotension decreased LOC

Agitation Resp Depression

Pin Point Pupils

Sympatthomimetic

Methamphetamine Amphetamine

Agitation Tachycardia Fits

Hyperthermia

Sedative and Hypnotic

Diazepam Temazepam

Zopiclone Phenobarbital

Decreased LOC Ataxia

Slurred speech Hypotension

Cholinergic

Sarin Tabun

Dry flushed skin

Increased salivation

GI Upset Resp Depression

Anticholinergics

Atropine Buscopan Anti Histamines Anti Psychotics

Dry flushed skin

Dilated Pupils

Tachycardia Blurred vision

1.

Ensure a clear airway and adequate ventilation, particularly in obtunded patients. Ventilation may be required for respiratory depression.

2.

Gut decontamination is unlikely to be of benefit since ethanol is rapidly absorbed and activated charcoal does not significantly reduce the rate of absorption.

3.

Observe for at least 4 hours if > 0.4 mL/kg body weight of absolute ethanol had been ingested in a child (< 10 years) (i.e. 1 mL/kg 40% spirit, 4 mL/kg 10% wine or 8 mL/kg 5% beer).

Observe adults with features of moderate or severe toxicity for a minimum of 6 hours.

4.

Monitor pulse, blood pressure, cardiac rhythm, conscious level, respiratory rate and body temperature.

5.

Monitor blood glucose in all patients.

6.

Measure urea, electrolytes, creatinine kinase, LFTs, arterial blood gases and blood ethanol concentration in patients with features of moderate to severe toxicity and perform 12 lead ECG.

7.

Correct hypoglycaemia as quickly as possible. If the patient is awake give oral glucose followed by a carbohydrate meal.

Adults: If the patient is drowsy or unconscious give up to 250 mL 10% or 125 mL 20% glucose IV rapidly (titrated to patient responsiveness).  Continue an appropriate infusion to maintain consciousness and/or normal blood glucose.  If hypoglycaemia persists 50 mL 50% glucose IV may be given but is irritant to veins and can cause skin necrosis in cases of extravasation.

Children: Initially 5 mL/kg of 10% glucose IV repeated as necessary.  Higher concentrations of glucose may be required for severe hypoglycaemia.

Glucagon is rarely effective.

8.

Consider treating chronic alcohol abusers with intravenous thiamine (e.g. Pabrinex 10 mL over 30 mins) to protect against the onset of Wernicke’s encephalopathy. Intravenous thiamine MUST be administered before giving dextrose to chronic alcohol abusers.

9.

Correct hypotension by raising the foot of the bed and by giving an appropriate fluid challenge. Treat brady and tachyarrhythmias appropriately.

Children failing to respond to an appropriate intravenous fluid bolus require early discussion with the local paediatric intensive care unit (PICU).

Adults: If severe hypotension persists despite the above measures, then central venous pressure monitoring should be considered. Manage in a critical care area or involve the critical care outreach team.

When hypotension is mainly due to decreased systemic vascular resistance, drugs with alpha-adrenergic activity such as noradrenaline or high dose dopamine (10-30 micrograms/kg/min) may be beneficial. The dose of vasopressor should be titrated against blood pressure.

When hypotension is believed to be due to reduced cardiac output (e.g. where global hypokinesia is demonstrated on echocardiography) inotropic drugs such as dobutamine, or in severe cases adrenaline, may be beneficial.

NOTE: Both negative inotropic and vasodilator actions may both be present, particularly in mixed overdoses.

If severe hypotension further persists discuss with your local poisons information service: in the UK NPIS 0844 892 0111, in Ireland NPIC (01) 809 2566.

1.

Maintain a clear airway and adequate ventilation if indicated.

2.

The benefit of gastric decontamination is uncertain. Consider activated charcoal (charcoal dose: 50 g for an adult, 1 g/kg for a child) in adults or children who have taken more than a potentially toxic amount within 1 hour, provided the airway can be protected.

3.

Patients who are asymptomatic at 4 hours are unlikely to develop severe toxicity.

4.

Monitor level of consciousness, respiratory rate, pulse oximetry and blood pressure in symptomatic patients.

5.

Consider arterial blood gas analysis in patients who have a reduced level of consciousness (GCS < 8; AVPU scale P or U) or have reduced oxygen saturations on pulse oximetry.

6.

Correct hypotension by raising the foot of the bed and by giving an appropriate fluid challenge. Treat brady and tachyarrhythmias appropriately.

Children failing to respond to an appropriate intravenous fluid bolus require early discussion with the local paediatric intensive care unit (PICU).

Adults: If severe hypotension persists despite the above measures, then central venous pressure monitoring should be considered. Manage in a critical care area or involve the critical care outreach team.

When hypotension is mainly due to decreased systemic vascular resistance, drugs with alpha-adrenergic activity such as noradrenaline or high dose dopamine (10-30 micrograms/kg/min) may be beneficial. The dose of vasopressor should be titrated against blood pressure.

When hypotension is believed to be due to reduced cardiac output (e.g. where global hypokinesia is demonstrated on echocardiography) inotropic drugs such as dobutamine, or in severe cases adrenaline, may be beneficial.

NOTE: Both negative inotropic and vasodilator actions may both be present, particularly in mixed overdoses.

7.

Supportive measures as indicated by the patient's clinical state.

8.

Flumazenil (Anexate), a benzodiazepine antagonist, is available but should rarely be required. It may be required in children who are naive to benzodiazepines or patients with COPD as an alternative to ventilation. Flumazenil has a short half-life (about an hour) and in this situation an infusion may therefore be required.

Flumazenil should not normally be used in patients with a history of seizures, head injury, chronic benzodiazepine use, co-ingestion of a benzodiazepine and tricyclic antidepressant or other proconvulsant - Instructions for its use follow.