The “Big 5” Toxidromes

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Poison Control Hotline: 1-800-222-1222

Step 1: Evaluate the Airway

• General principles
  • “If they can’t speak, they can’t control their airway”
  • “If GCS is <8, intubate”
• In the real world, it’s a clinical judgement call

Step 2: Toxicology History

• What did they take?
• How much did they take?
• Why did they take it?
• When did they take it?

Step 3: Toxicology Exam

• Vital signs
• Pupils
• Skin

Step 4: Medication List

• Make note of all bottles with patient
• Make EXTRA note if any pills seem to be missing
• Bonus points if you bring your attending a med list

Step 5: Common Toxicology Tests

• Assessing for damage
  • Electrolytes
  • Liver function test
  • EKG
  • Pregnancy
• Assessing for co-ingestion
  • Serum acetaminophen
  • Serum salicylate
  • Serum alcohol
  • Urine drug screen

The “Big 5” Toxidromes

• Anticholinergic
  • Increased vitals
  • Big pupils
  • Dry skin
  • Treatment – Physostigmine (rarely given)
• Cholinergic
  • Decreased vitals
  • Small pupils
  • Moist skin
  • Treatment – Atropine
• Opioid
  • Decreased vitals
  • Small pupils
  • Dry skin
  • Treatment – Naloxone
• Sedative/Hypnotic
  • Decreased vitals
  • Normal pupils
  • Dry skin
  • Treatment – Flumazenil (rarely given)
• Sympathomimetics
  • Increased vitals
  • Big pupils
  • Moist skin
  • Treatment – Benzodiazepines

Additional Reading

• NBME Shelf Review – Ophthalmology and Toxicology (EM Clerkship)
• Toxidromes (Admin EM)