 Hello, and welcome to EM Ottawa video series. Your next patient is a 45-year-old male who was found with a decreased level of consciousness. The family member who brought him in stated that maybe he's taken something. The patient is completely unable to provide a history. How do you find clues to decide what he has taken and whether he's taking a toxin? One of the ways is to see whether the patient has signs and symptoms that suggest a toxidrome. What is the toxidrome? It is a combination of signs and symptoms that suggest a specific class of toxin. You don't know what the patient has taken, but you know what type of toxin they might have taken. There are four main types of toxidromes. They are sympathomimetic, opioid, anticholinergic, and cholinergic. If you see signs and symptoms that fit with a particular toxidrome, you can tell what class of drug the patient may have taken. Without information, you can start treatment empirically without knowing what specific drug they took. To decide what kind of toxidrome the patient might have, we rely on one, vital signs, and two, physical findings. We will now discuss these four toxidromes and their treatment. First, sympathomimetic. These kind of drugs are mostly stimulants, such as amphetamines, cocaine. These are uppers. Patients with a sympathomimetic toxidrome will have sped up vital signs. They will have tachycardia, hypertension, hypothermia, and keyed up level of consciousness, so they're mostly agitated. They will seem to be hyper-excited. They would also have large pupils known as medriasis. On examination of the skin, it is flushed, warm, and diaphoretic. This is what patients with sympathomimetic toxidromes might look like. They're generally agitated, and their vital signs tend to be sped up. Patients who have sympathomimetic toxidrome often just need supportive care, meaning treatment for their symptoms rather than a specific antidote. They might need cooling for their high temperature, if they are agitated or if they have seizures. Benzodiazepines, such as lorazepam, or diazepam, are used. There's no specific antidote. Next, opioid toxidrome. Opioids include drugs such as morphine, fentanyl, things that we often treat pain with in the hospital. And other medications such as methadone or street drugs like heroin. This toxidrome is almost like the complete opposite of sympathomimetic syndrome. Patients with opioid toxidrome are much slower. They will have bradycardia, hypotension, low temperature, and low respiration rate. A patient with an opioid toxidrome might look like this. They often will have a decreased level of consciousness, and they might be difficult to rouse. Patients with opioid toxidrome die of hypoxia due to low respiratory rate. If the patient's respiratory rate is low, or if they're hypoxic, we will intervene by giving an antidote. The antidote is called naloxone. This reverses the effect of the opioid temporarily. We would also treat with intravenous fluid for the hypotension. Next, anticholinergic toxidrome. Anticholinergic toxins include medications such as chicyclic antidepressants, anti-allergy medications such as diphenhydramine, and anti-nausea medications such as dimenhydrenate. Anticholinergic toxidrome is a bit like sympathetic toxidrome. The patient can often have hypertension, tachycardia, hypothermia, agitation, and confusion. On examination, they often have big pupils. The skin is warm and flushed. This is where the similarity ends. In patients with anticholinergic toxidrome, the skin is dry. They also can have urinary retention. This can be remembered by the following Alice in Wonderland picture. Hot as a hair for the hypothermia, mad as a hatter for the confusion, dry as a bone for the dry skin, red as a heartbeat will make do with this because they're flushed and blind as a bat because of the big pupils. The treatment for anticholinergic toxidrome is mostly supportive, except for TCA which we will discuss in another video. Similarly to the other supportive treatment, it includes IV fluids and cooling for the hypothermic patient. There is an antidote but it's rarely used. If the patient is very agitated or if there are seizures, it is again treated by benzodiazepines. The last toxidrome is cholinergic toxidrome. This toxidrome is caused by toxins such as organophosphates in pesticides and insecticides. This toxidrome as you can guess is the opposite of anticholinergic syndrome. Their physical signs include mostly increased secretions. They include increased salivation, lacrimation, urination as opposed to the urinary retention in anticholinergic syndrome, diarrhea, GI emesis, or vomiting. Most importantly, it causes something about the heart rate which is the most worrisome part of the toxidrome. It causes significant bradycardia, that together with fluid loss and increased secretions from everywhere including the lungs causes the most morbidity and mortality in patients. It is like someone turned the tap on every part of the body including the GI tract, the lungs, and the GU tract. The treatment for cholinergic syndrome include atropine. It does two things, one it increases heart rate, two it decreases secretions. A specific antidote called pralidoxine can also be used to reverse the effects of the toxins. In summary, review the four types of toxidrome and their treatment. Just to recap, they are sympathomimetic, opioid, anticholinergic, and cholinergic. Thank you for watching.