Toxidromes Edited

8/8/2019 Toxidromes Edited

1/11

ToxidromesToxic-Syndromes

BUGS DRUGS SLUGS

Adapted from source


2/11

Cla ssifying Toxicity....y Bugs:

y Snak e Venomy Je llyfishy Conefish, Tic ks

y

Drugs:y Stimu la nts:y Coca ine, Amphet a mines

y Depress a nts:y Opia tes, A lcoho ls, Benzodi a zepines, GHB

y Hall ucinogensy

Keta mine, Ca nn ab isy Prescription:

y TCA, Metformin, P a ra cet a mo ly Slugs:

y Cya nide


3/11

Bugs: Sn ak es

y Venoms:y Species dependent.

y Myotoxins, Ca rdiotoxins, H a emo lysins,a ntico a gu la nts, proco a gu la nts.

y

Symptoms of neurotoxin envenom a tion:Ptosis, Respir a tory distress, Voice ch a nges->global pa ral ysis. Mx: Intu ba tion, venti lla tion,a ntivenom.

y Antivenom: Specific, Po lyval ent. Often e llicitsa na phy la ctic/ a na phy la ctoid re a ction.

y Snak e venom toxicity me a sured in LD50

(mice). King Cob ra 1.91mg/ k g. (15000). In la ndTa ipa n (0.01mg/ k g = 500,000).

y Bra zilia n pit viper Bothrops j a ra ra ca Origin of the A CE inhi b itors.


4/11

Bugs: Je llyfish

y Iruka ndji Syndrome:y Carukia barnesi y 1964, Dr. J a ck stung himse lf, his son, a nd

a local lifegu a rd, a nd o b served thesymptoms. [

y ca techo la mine excessy Tips of the nem a tocysts inject venom

into lymph a tics.y Symptoms: severe he a da che, ba cka che,

musc le p a ins, chest a nd ab domin al pa in,

na

usea

a

nd vomiting, swea

ting,a

nxiety,hypertension, t a chyc a rdia a ndpu lmon a ry edem a . impending doom".

y Trea tment: Vineg a r, Opioids,?M a gnesium..... ? Cl onidine.


5/11

Bugs: Conefish, Tic k s

y Coneshe ll:y Pred a tory se a sn a ils.y Ra du la r tooth (h a rpoon like ho llow ba rb ) a tt a ched to thro a t a nd

which is fired a t prey. Conotoxin is injected through tooth from thepoison g la nds in the thro a t.

y Tooth c a n b e fired in a ny direction (even ba ck wa rds).y Conotoxin (Neurotoxins): Simi la r to tetrodoxins. (N a+ ch a nne l

bl oc kers).y Symptoms: V a ry a ccording to species. P a in a t site, a git a tion,

num b ness/ting ling... Ca rdi a c a rrhythmi a ...y ?The future of p a in re lief: 1000x more potent then morphine. Tri al s

show effic a cy in post surgic al a nd neurop a thic p a in. First drugsZiconotide recent ly a pproved b y FDA (2004) Prial t .

y Ticks: She llba ck tick (pa ral ysis tic k )y Symptoms: Itch, coughing, a ch a nge in voice, vomiting, progressing to

we ak ness a nd st a ggering in the hind legs, eventu all y le a ding to fu ll pa ral ysis, respir a tory f a ilure.

y Trea tment: Antivenom


6/11

Drugs : Stimu la ntsy Coc a ine

y Mech a nisms of a ction: B loc ks the Reupt ak e of Dop a mine,Serotonin, Nor-Adren al ine.

y Symptoms: Euphori a , Agita tion, P a ra noi a , Hyperref lexia ,drowsiness, convu lsions.

y Signs: Ta chyc a rdi a , m al igna nt hypertension (intr a cra nial ha emorrh a ge), Coron a ry a rtery sp a sm (MI, VF),Hyperthermi a (Rhab domyo lysis, Acute Ren al Fa ilure,

Myoca

ridal

Inf a

rction).y Trea tment: Toxic dose dependent upon to ler a nce, presenceof other drugs a nd route of a dministr a tion. >1gr a m usu all yf a tal (smugg ling).

y Vital s monitoring (NIBP, SpO2, EC G); Activa ted ch a rco al if ingestion within the hour.

y Specific: Benzodi a zipines for a gita tion/psychosis, a 2-a gonists(clonidine , dexmedetomidine), L ab et a o lo l (a 1 bl oc ker) ordirect v a sodi la tors. Ca ution with b et a bl oc kers due tounopposed al ph a stimu la tion. Coo ling. Convu lsions....

Intu ba tion, Venti lla tion, Sed a tion/P a ral ysis.y Amphet a mines

y Mech a nisms of a ction: Indirect a cting symp a thomimetica mine. Enters presyn a ptic nerve termin al via NorAdReupt ak e. Enters vesic les vi a VMAT a nd disp la ces NorAdwhich enters cytoso l a nd syn a ptic c left vi a esc a pe throughNorAd tr a nsporter.

y Symptoms: Swe a ting, Dry Mouth, Anxiety, Dehydr a tion....Hypon a tr a emi a from excess H2O consumption. Mx: As percoc a ine. Hypertonic S al ine if Hypon a tr a emi a is severe.


7/11

Drugs: Depress a nts

y Opia tesy Mech a nisms of a ction: Mu, K a pp a , La m b da (Ce ll Hyperpo la risa tion).y Syndrome: Miosis, Sed a tion, Respir a tory Depression.y Trea tment: N al oxone: .1-.4mg Q15mins. life import a nt. I + V if

nal oxone insufficient.y

Alcoho

ls (Meth

ano

l,

Ethy

lene G

lyco

l)y Agents non-toxic, met ab o lites (formic a cid, g lyco lic a cid) extreme ly

toxic.y Met ab o lic a cidosis, Optic Nerve Toxicity, Ren al Fa ilure...y Signs: Incre a se in osmo la r a nd a nion g a ps.y Activa ted ch a rco al of no b enefit. EtOH tre a tment of choice in the

pa st (competitive met ab o lism). New Rx = Fomepizo le. Fo linic Acid formet ab o lism of formic a cid. H a emodi al ysis if severe a cidosis.

y Benzodi a sepinesy

Act on GABA receptor.y Common ly seen, uncommon ly severe.y Symptoms: Sed a tion, Dys a rthri a , Ata xia , Nyst a gmus, Confusion.y Trea tment: A C if within 1 hr; F lum a zeni l a s di a gnostic a id on ly, note

contr a indica tions b efore a dministr a tion.y GHB

y Syndrome: Com a , Convu lsions, Br a dyc a rdi a , Hypotension,Respir a tory depression.

y Rx: Supportive c a re for most, Benzodi a zepines for convu lsions.


8/11

Hall ucinogens

y Keta miney NMDA receptor a nt a gonist.y Synthesised in 1962 a nd first uti lised on

US so ldiers during the vietn a m w a r.y Anesthesi a , Anal gesi a , Amnesi a ,

Immo b ility + Pyscho logic al re a ctions....Dissoci a tive st a te.

y Tre a tment: Supportive, b enzodi a zepines,I+ V if nea r a na esthetic st a te.

y Ca nn ab isy Acts on endogenous c a nn ab inoid

receptors. High incidence of psychogenicre a ctions.

y Potenti al symptoms of OD: P a ra noidpscyhosis, a ta xia , nyst a gmus, t a chyc a rdia ,confusion.

y Potenti al ro le a s future a nal gesic (whennon- CNS a cting a gents iso la ted).


9/11

Drugs: Prescription Medicine

y TCAy Syndrome: Anti cho linergic effects Wa rm dry s k in,

ta chyc a rdi a , bl urred vision, mydri a sis, urin a ryretention. Severe: Respir a tory depression, CNSdepression, Ca rdia c Arrhythmi a s, Convu lsions.Arrhythmi a s like ly if QRS >100ms; QRS >160ms...Seizures. Ca rdi a c a rrhythmi a s due to s lowing of Ph a se

0 depo la risa tion.y Rx: AC , Continuous c a rdi a c monitoring, intention al

alkal inis a tion of bl ood to pH >7.45 (reduces a va ilab ilityof free/ a ctive drug) a chieved vi a hyperventi la tiona nd N a HCO3). Arrythmi a Ma na gment: Everythingexcept c la ss 1 a .

y Metforminy Mech a nisms of a ction: Incre a ses g lucose tr a nsport

into g lucose uti lizing ce lls a nd decre a seshep a ticgluconeogenisis. Bigu a nide ther a py decre a ses thea ctivityof the enzyme pyruv a te dehydrogen a se a ndthe tr a nsport of mitochondri al reducing a gents, a ndthus enh a nces a na ero b ic met ab o lism.

y Toxicity: Ca n resu lt in Type B (non-hypoxic) la ctica cidosis. Metformin s propensity to shift ce lls intoa na ero b ic met ab o lism is not depend a nt on a la ck of oxygen a nd, in the presence of reduced insu lin,incre a ses production of precursors for the tric a rb oxy lica cid cyc le. The inhi b ition of pyruv a te dehydrogen a sele a ds to a decre a sed ab ility to ch a nne l theseprecursors into a ero b ic met ab o lism which c a usesincre a sed met ab o lism of pyruv a teto la ct a te a nd a n

incre a se in la ctic a cid production.y Trea tment: H a emodi al ysis.


10/11

Pa ra cet a mo l

y Doses >10gr a ms ( a du lts) h a ve the potenti al toexceed hep a tic g lut a thione conjug a tion withthe resu lta nt toxic met ab o lites. P la sm a concentr a tions > 200mg/L a t 4hrs or >50mg/La t 12hrs usu all y resu lt in hep a tic d a m a ge.

y Symptoms: N/V m a y b e on ly symptomsiniti all y.

y Trea tment: Drug leve ls, fo llow the nomogr a m.Administer A C. N-Acety lcysteine 150mg/ k gfo llowed b y 50mg/ k g over 4 hrs. See k expertopinion from tr a nsp la nt a tion centre if ongoing deterior a tion...

y N-Acety lcystein: a ugments g lut a thionereserves in the b ody a nd, together withglut a thione, direct ly b ind to toxic met ab o lites.


11/11

Slugs - Cya nide

y Any compound cont a ining the c a rb on---nitrogengroup. CN- is extreme ly toxic...

y Uses: M al igna nt Hypertension (N a Nitroprusside),Co louring (Pott a sium ferrocy a nide), Go ld a nd Si lver

Mining, Fumiga

tion, Ill

egal

Fishing, Genocide.y Hydrogen Cya nide: Li b ra tes the cy a nide a nionwhich inhi b its the enzyme cytochrome C oxid a se(4 th comp lex of e lectron tr a nsport ch a in inmitochondri a ). Resu lts in switch from a ero b ic toa na ero b ic met ab o lism.

y Syndrome: R a pid ly f a tal , if however one survivesthen: hypotension, met ab o lic a cidosis, respir a torydepression, com a .

y Rx: Inhal ed a my l nitr a te a nd 100% oxygen. Dico bal tedet a te. Sodium Thiosu lph a te. Hydroxoco bala min.Na HCO3 to tre a t met ab o lic a cidosis.

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