Stereotypic Toxidromes

Created on Tue, 12/22/2015 - 08:01
Last updated on Wed, 07/12/2017 - 18:01

Next Chapter:

Though this does not come up in any of the prior SAQs, it is probably important to recall the features of these characteristic toxin syndromes. Of specific interest is the list of clinical differences between serotonin syndrome and neuroleptic malignant syndrome, which I can never remember.

Anticholinergic syndrome

  • Blind as a bat: mydriasis, dilated pupils and the inability to accomodate
  • Mad as a hatter: delirium
  • Dry as a bone: inability to form sweat
  • Red as a beet: skin flushing
  • Hot as a hare: fever
  • Also...
    • ileus
    • urinary retention
    • tachycardia
    • coma

Cholinergic syndrome

SLUDGEMS:

  • Siallorhoea
  • Lacrimation
  • Urination
  • Diarrhoea
  • Gastrointestinal distress: abdominal pain due to hypermotility
  • Emesis
  • Miosis - constricted pupils
  • Seizures
  • Also...
    • tachycardia
    • bronchorrhoea
    • hypothermia
    • diaphoresis
    • muscle fasciculations
    • paralysis

Sympathomimetic syndrome

HAH STUPOR

  • Hypertension
  • Agitation
  • Hyperreflexia
  • Seizures
  • Tachycardia
  • Urination
  • Piloerection
  • Ocular- pupil dilatation, mydriasis
  • Rhabdomyolysis

Opiate syndome

BUM HIDE:

  • Bradycardia
  • Urinary retention
  • Miosis
  • Hypotension
  • Ileus
  • Decreased respiratory drive
  • Emesis
  • Also...
    • decreased cough reflex
    • hypothermia
    • hyporeflexia

Serotonin syndrome

RASCAL

  • Rhabdomyolysis
  • Agitation / hypervigilance
  • Seizures
  • Clonus
  • Autonomic overdrive - tachycardia, hypertension
  • Large pupils - mydriasis

also...

    • hyperreflexia
    • hyperthermia

Neuroleptic malignant syndrome

FEVER LAD

  • Fever
  • Encephalopathy
  • Vitals unstable - hyper or hypotension, brady or tachycardia
  • Elevated enzymes - CK
  • Rigidity of the muscles, hypertonia
  • Leucocytosis
  • Acidosis
  • Diaphoresis

Also, low serum iron (acute phase response)

Cinchonism syndrome - quinine / quinidine

  • Flushed skin
  • Tinnitis and deafness
  • Skin rash, photosensitivity
  • Blindness
  • Coma
  • Cardiotoxicity: long QRS

Telling serotonin sysndrome from neuroleptic malignant syndrome

  • Serotonin syndrome has an earlier onset (~ 12hrs)
  • Serotonin syndrome has HYPER-reflexia, whereas in NMS the reflexes are depressed
  • Serotonin syndrome has clonus - NMS merely has rigidity
  • Serotonin syndrome features dilated pupils - NMS does not
  • Serotonin syndrome has hyperactive bowels, whereas NMS may have ileus