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.

Toxidrome	Clinical Manifestation	Potential Vital Sign Changes	Causative Agents
ANTICHOLINERGIC	hot as a hare (fever)	tachycardia, hyperthermia	antihistamines, 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
CHOLINERGIC	MUSCARINIC EFFECTS: Diarrhea Urination Miosis Bradycardia Bronchorrhea Bronchospasm Emesis Lacrimation Salivation	bradycardia	organophosphate 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	tachycardia and hypertension
OPIOID	sedation, stupor, coma, miosis	bradypnea, hypotension	opioids, clonidine, tizanidine
SEDATIVE HYPNOTIC	sedation, stupor, coma	bradypnea, hypotension	benzodiazepines, barbiturates, alcohols, anticonvulsants
SYMPATHOMIMETIC	anxiety, CNS agitation, seizures, diaphoresis, delusions, psychosis, active bowel sounds, mydriasis that responds to light	hypertension, tachycardia, hyperthermia	cocaine, amphetamines, synthetic (e.g. Molly), synthetic cannabinoids (e.g. K2, Spice), synthetic cathinones (e.g. bath salts, flakka), stimulants
SALICYLATES	tachypnea, hyperpnea, AMS, confusion, seizures, acid-base disturbance	tachypnea, hyperpnea, neuroglycopenia (low CSF glucose)	aspirin, oil of wintergreen, bismuth subsalicylate
HALLUCINOGENS	AMS, hallucinations, delusions, agitation, psychosis	tachycardia, tachypnea, hypertension	ecstasy, 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
BP	HR	RR	T	MENTAL STATUS	PUPILS	GI	SKIN
- / ↑	↑	±	↑	delirium	↑	↓	dry, flush
CHOLINERGIC (MUSCARINIC)
BP	HR	RR	T	MENTAL STATUS	PUPILS	GI	SKIN
±	±	- / ↑	-	normal to depressed	±	↑	diaphoretic
HYPNOTIC
BP	HR	RR	T	MENTAL STATUS	PUPILS	GI	SKIN
↓	↓	↓	- / ↓	depressed, agitated	±	↓	-
OPIOID
BP	HR	RR	T	MENTAL STATUS	PUPILS	GI	SKIN
↓	↓	↓	↓	depressed	↓	↓	-
SYMPATHOMIMETIC
BP	HR	RR	T	MENTAL STATUS	PUPILS	GI	SKIN
↑	↑	↑	↑	agitated	↑	- / ↑	diaphoretic