Toxidromes

There are multiple factors that affect a patient’s presentation and treatment options. The information herein is intended for educational purposes and should not be used to supersede clinical judgement or toxicologic consultation.

ToxidromeClinical ManifestationPotential Vital Sign ChangesCausative Agents
ANTICHOLINERGIChot as a hare (fever)tachycardia, hyperthermiaantihistamines, atropine, scopolamine, angel trumpet, jimson weed, cyclic antidepressants, antipsychotics
dry as a bone (dry mucosa)
red as a beet (flushing)
blind as a bat (mydriasis)
mad as a hatter (agitation/delirium)
full as a flask (urinary retention)
tachy as a leisure suit (tachycardia)
hypoactive bowel sounds
CHOLINERGICMUSCARINIC EFFECTS:
Diarrhea
Urination
Miosis
Bradycardia
Bronchorrhea
Bronchospasm
Emesis
Lacrimation
Salivation
bradycardiaorganophosphate pesticides, carbamate pesticides, cholinergic mushrooms, nerve gas chemical warfare agents, pyridostigmine, neostigmine, physostigmine
NICOTINIC EFFECTS:
Mydriasis
Tachycardia
Weakness
Hypertension
Fasciculations
tachycardia and hypertension
*NOTE: a mixture of muscarinic and nicotinic effects can be seen throughout the clinical course
OPIOIDsedation, stupor, coma, miosisbradypnea, hypotensionopioids, clonidine, tizanidine
SEDATIVE HYPNOTICsedation, stupor, comabradypnea, hypotensionbenzodiazepines, barbiturates, alcohols, anticonvulsants
SYMPATHOMIMETICanxiety, CNS agitation, seizures, diaphoresis, delusions, psychosis, active bowel sounds, mydriasis that responds to lighthypertension, tachycardia, hyperthermiacocaine, amphetamines, synthetic (e.g. Molly), synthetic cannabinoids (e.g. K2, Spice), synthetic cathinones (e.g. bath salts, flakka), stimulants
SALICYLATEStachypnea, hyperpnea, AMS, confusion, seizures, acid-base disturbancetachypnea, hyperpnea, neuroglycopenia (low CSF glucose) aspirin, oil of wintergreen, bismuth subsalicylate
HALLUCINOGENSAMS, hallucinations, delusions, agitation, psychosistachycardia, tachypnea, hypertensionecstasy, Molly, LSD, peyote, psilocybin-containing mushrooms, dextromethorphan, cannabinoids, phencyclidine

AMS- altered mental status
CSF- cerebrospinal fluid
CNS- central nervous system

*NOTE: The toxidromes assume a single substance or class exposure. Exposure to multiple classes as well as patient specific variables can result in mixed or partial toxidromes. These simplified toxidromes should not take the place of clinical judgment.

Toxidrome Summary

ANTICHOLINERGIC
BPHRRRTMENTAL STATUSPUPILSGISKIN
- / ↑±deliriumdry, flush
CHOLINERGIC (MUSCARINIC)
BPHRRRTMENTAL STATUSPUPILSGISKIN
±±- / ↑-normal to depressed±diaphoretic
HYPNOTIC
BPHRRRTMENTAL STATUSPUPILSGISKIN
- / ↓depressed, agitated±-
OPIOID
BPHRRRTMENTAL STATUSPUPILSGISKIN
depressed-
SYMPATHOMIMETIC
BPHRRRTMENTAL STATUSPUPILSGISKIN
agitated- / ↑diaphoretic