2017 / 12 December

Clinical Toxidromes

Clinical Toxidromes are a group of specific signs and symptoms that suggest a particular poisoning class. Rapid recognition of a toxidrome is essential because it can determine initial management strategies. Vital signs, pupils, physical exam (abdominal examination) and mental status to help identify the toxidrome.

Sympathomimetic Toxidrome/Withdrawal 

  • Drugs:  Caffeine, cocaine, amphetamines, methamphetamines, Ritalin, LSD, Theophylline, MDMA
  • Characteristics:  Mimics “Fight or Flight” response-Hyperthermia, Tachycardia,  Hypertension, Diaphoresis,  Delusions, Paranoia,  Mydriasis,  Bowel sounds present
  • Treatment:  Benzos/Sedation

Anticholinergic Toxidrome 

  • Drugs:  Atropine, scopolamine,   antihistamines (Chlorpheniramine,  Hydroxyzine, Dimenhydrinate, Diphenhydramine),  Antipsychotics (Chlorpromazine, Clozapine, Olanzapine, Quetiapine),  Cyclic antidepressants (Amitriptyline, Imipramine, Nortriptyline)
  • Characteristics:  Mad as a hatter, Hot as hell, Red as a beat, Dry as a bone, and Blind as a bat
  • Treatment: Physostigmine (acetylcholinesterase inhibitor)

Cholinergic Toxidrome 

  • Drugs: Organic phosphorous compounds (organophosphate), such as parathion. Organophosphates are often components of insecticides
  • Characteristics: The symptoms can be remembered by the mnemonic DUMBBELSS: Diarrhea, Urination, Miosis, Brochospasm, Bradycardia, Excitation, Lacrimation, Sweating, and Salivation
  • Treatment: Atropine (muscarinic receptor competitive inhibitor), Pralidoxime (binds to organophosphate-inactivated acetylcholinesterases)

Opioid Toxidrome

  • Drugs: Morphine, Codeine, Tramadol, Heroin
  • Characteristics: Pinpoint pupils, Altered mental status,  Decreased bowel sounds, Respiratory depression
  • Treatment: Naloxone

Sedative-Hypnotics Toxidrome 

  • Drugs: Barbituates and Benzodiazepines
  • Characteristics: Disinhibition, Sedation, Nausea/vomiting, Myoclonic Movements, Seizures
  • Treatment: ABCs, Prevention of absorption,  Elimination enhancement and flumazenil for benzodiazepine intoxication

If you want to learn more about Cholinergic and Anticholinergic Toxicity, don’t miss this video (link)

Remember, ABC (resuscitation) followed by decontamination are the first steps in the poisoned patient algorithm. Consult Poison Control for assistance.


  • Holstege CP, Borek HA. Toxidromes. Crit Care Clin. 2012 Oct;28(4):479-98. doi:10.1016/j.ccc.2012.07.008
  • Holstege CP, Dobmeier SG, Bechtel LK. Critical care toxicology. Emerg Med Clin North Am. 2008 Aug;26(3):715-39, viii-ix. doi: 10.1016/j.emc.2008.04.003.
  • Boyle JS, Bechtel LK, Holstege CP. Management of the critically poisoned patient. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2009;17:29. doi:10.1186/1757-7241-17-29.
  • McLendon K, Bhimji SS. Atropine. [Updated 2017 Dec 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470551/

Further reading:

  • Approach to Acute Poisoning (link)

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