Toxicology Reference

Rapid reference for toxidromes, overdoses, and antidotes.

Acetaminophen (Paracetamol)

Antidote: N-acetylcysteine (NAC)

Toxidrome / Presentation

  • Phase 1 (0-24h): Asymptomatic, N/V
  • Phase 2 (24-72h): RUQ pain, elevated AST/ALT
  • Phase 3 (72-96h): Fulminant hepatic failure, jaundice, encephalopathy

Management Steps

  • Activated charcoal if within 1-2 hours of ingestion
  • Administer IV or PO NAC based on Nomogram
  • Liver transplant evaluation for severe hepatotoxicity (King's College Criteria)

Opioids (Heroin, Fentanyl, Oxycodone)

Antidote: Naloxone (Narcan)

Toxidrome / Presentation

  • Respiratory depression (RR < 12)
  • Miosis (pinpoint pupils)
  • CNS depression / Coma
  • Decreased bowel sounds

Management Steps

  • Airway management and ventilatory support
  • Administer Naloxone 0.4-2.0 mg IV/IM/IN, titrate to respiratory rate
  • Monitor for rebound toxicity due to short half-life of Naloxone

Beta-Blockers

Antidote: Glucagon, High-Dose Insulin Euglycemic Therapy (HIET)

Toxidrome / Presentation

  • Bradycardia
  • Hypotension
  • Hypoglycemia (especially in children)
  • Cardiogenic shock / Heart Failure
  • Bronchospasm

Management Steps

  • IV Fluids and Atropine for initial bradycardia
  • Glucagon (stimulates cAMP bypassing beta receptors)
  • High-Dose Insulin (helps myocardium utilize carbs)
  • Vasopressors (Epinephrine) if refractory

Anticholinergics (Diphenhydramine, TCA, Jimson weed)

Antidote: Physostigmine (rarely used, consult Tox)

Toxidrome / Presentation

  • Mad as a hatter (delirium/hallucinations)
  • Blind as a bat (mydriasis/dilated pupils)
  • Red as a beet (flushed skin)
  • Hot as a hare (hyperthermia)
  • Dry as a bone (dry mouth/skin, urinary retention)

Management Steps

  • Supportive care, cooling
  • Benzodiazepines for agitation and seizures
  • Sodium bicarbonate if QRS prolongation (from TCA)

Calcium Channel Blockers

Antidote: Calcium, High-Dose Insulin Euglycemic Therapy (HIET)

Toxidrome / Presentation

  • Hypotension
  • Bradycardia
  • Hyperglycemia (classic differentiator from beta-blockers)
  • Cardiogenic shock

Management Steps

  • Calcium Gluconate or Chloride IV
  • Glucagon
  • High-Dose Insulin (drives glucose into myocardial cells)
  • Vasopressors

Organophosphates (Cholinergics, Nerve Agents)

Antidote: Atropine, Pralidoxime (2-PAM)

Toxidrome / Presentation

  • DUMBELS: Diarrhea, Urination, Miosis, Bradycardia, Bronchorrhea, Emesis, Lacrimation, Salivation/Sweating
  • Muscle fasciculations / Weakness (Nicotinic effects)

Management Steps

  • Decontamination (remove clothing, wash skin)
  • Atropine (titrate to drying of respiratory secretions, NOT heart rate)
  • Pralidoxime (regenerates acetylcholinesterase, must be given early)

Digoxin

Antidote: Digoxin-specific antibody fragments (Digibind)

Toxidrome / Presentation

  • Nausea/Vomiting (early)
  • Visual changes (yellow/green halos)
  • Arrhythmias (PVCs, AV block, virtually any arrhythmia)
  • Hyperkalemia (in acute toxicity)

Management Steps

  • Administer Digibind for severe life-threatening arrhythmias or hyperkalemia > 5.0
  • Manage hyperkalemia
  • Avoid calcium administration (historically thought to cause 'stone heart', though recent data is mixed)

Iron

Antidote: Deferoxamine

Toxidrome / Presentation

  • Phase 1: Severe N/V/D, abdominal pain, GI bleeding
  • Phase 2 (Latent): False recovery
  • Phase 3: Shock, severe metabolic acidosis
  • Phase 4: Hepatic failure
  • Phase 5: Bowel scarring/strictures

Management Steps

  • Whole bowel irrigation (activated charcoal does NOT bind iron)
  • IV Deferoxamine for severe toxicity (produces 'vin rosé' colored urine)

Salicylates (Aspirin)

Antidote: Sodium Bicarbonate

Toxidrome / Presentation

  • Tinnitus (early sign)
  • Hyperventilation / Tachypnea
  • Nausea/Vomiting
  • Altered mental status
  • Hyperthermia (late/severe)

Management Steps

  • Activated charcoal if early
  • Urine alkalinization with Sodium Bicarbonate (traps ion in urine)
  • Hemodialysis for severe cases, renal failure, or altered mental status

Carbon Monoxide (CO)

Antidote: 100% Oxygen, Hyperbaric Oxygen Therapy (HBO)

Toxidrome / Presentation

  • Headache
  • Nausea/Vomiting
  • Dizziness
  • Altered mental status / Coma
  • Cherry-red skin (rare, classic post-mortem finding)

Management Steps

  • Remove from exposure
  • 100% O2 via non-rebreather mask
  • Hyperbaric Oxygen for pregnant patients, syncope, coma, myocardial ischemia, or severely elevated levels

Cyanide

Antidote: Hydroxocobalamin or Cyanide Antidote Kit

Toxidrome / Presentation

  • Rapid onset of coma / seizures
  • Cardiovascular collapse / Shock
  • Bitter almond odor (genetic ability to smell)
  • Lactic acidosis

Management Steps

  • Hydroxocobalamin (Cyanokit - binds CN to form cyanocobalamin / Vitamin B12)
  • Alternative: Sodium nitrite + Sodium thiosulfate
  • Aggressive supportive care

Toxic Alcohols (Methanol / Ethylene Glycol)

Antidote: Fomepizole, Hemodialysis

Toxidrome / Presentation

  • Methanol: Visual changes ('snowstorm' vision), blindness
  • Ethylene Glycol: Renal failure, flank pain
  • Both: Inebriation followed by severe high anion gap metabolic acidosis

Management Steps

  • Fomepizole (competitively inhibits alcohol dehydrogenase)
  • Alternative: Ethanol (saturates enzyme)
  • Hemodialysis for severe acidosis or organ damage
  • Cofactors: Folic acid (Methanol), Thiamine/Pyridoxine (Ethylene Glycol)

Tricyclic Antidepressants (TCAs)

Antidote: Sodium Bicarbonate

Toxidrome / Presentation

  • Anticholinergic signs (delirium, mydriasis, dry mouth)
  • Cardiotoxicity (arrhythmias, wide QRS, hypotension)
  • CNS depression / Seizures (The 3 C's: Coma, Convulsions, Cardiotoxicity)

Management Steps

  • Sodium Bicarbonate (overcomes sodium channel blockade, narrows QRS)
  • Benzodiazepines for seizures
  • AVOID physostigmine (can cause cardiac arrest)

Benzodiazepines

Antidote: Flumazenil (Use with extreme caution)

Toxidrome / Presentation

  • CNS depression
  • Slurred speech
  • Ataxia
  • Relatively normal vital signs (unlike opioids/barbiturates)

Management Steps

  • Supportive care and airway protection
  • Flumazenil is generally AVOIDED due to high risk of precipitating intractable seizures, especially in chronic users or co-ingestion of pro-convulsants

Lithium

Antidote: None (Hemodialysis for severe cases)

Toxidrome / Presentation

  • Acute: Nausea, vomiting, diarrhea
  • Chronic: Tremor, ataxia, confusion, hyperreflexia, seizures

Management Steps

  • Aggressive IV hydration with Normal Saline
  • Hemodialysis for levels > 4 mEq/L (or > 2.5 with severe symptoms/renal failure)

Sympathomimetics (Cocaine, Amphetamines)

Antidote: Benzodiazepines

Toxidrome / Presentation

  • Tachycardia
  • Hypertension
  • Mydriasis (dilated pupils)
  • Agitation / Paranoia
  • Diaphoresis (sweating - distinguishes from anticholinergics)

Management Steps

  • Benzodiazepines for agitation and cardiovascular toxicity
  • Cooling for hyperthermia
  • AVOID pure beta-blockers (can cause unopposed alpha vasoconstriction/hypertensive crisis in cocaine)

Serotonin Syndrome

Antidote: Cyproheptadine

Toxidrome / Presentation

  • Altered mental status (agitation/confusion)
  • Autonomic hyperactivity (tachycardia, diaphoresis, hyperthermia, diarrhea)
  • Neuromuscular abnormalities (hyperreflexia, clonus - especially in lower extremities)

Management Steps

  • Discontinue offending agents
  • Benzodiazepines for agitation
  • Cyproheptadine (serotonin antagonist) for moderate/severe cases
  • Active cooling

Sulfonylureas

Antidote: Octreotide, Dextrose

Toxidrome / Presentation

  • Profound, recurrent, and prolonged hypoglycemia
  • Diaphoresis, tachycardia
  • Confusion, coma, seizures

Management Steps

  • Initial correction with IV Dextrose (D50)
  • Octreotide (somatostatin analog) prevents recurrent hypoglycemia by inhibiting endogenous insulin release
  • Provide oral carbohydrates

Methemoglobinemia

Antidote: Methylene Blue

Toxidrome / Presentation

  • Cyanosis (unresponsive to supplemental oxygen)
  • Chocolate-brown colored blood
  • Dyspnea, fatigue
  • Altered mental status / Seizures in severe cases

Management Steps

  • Administer Methylene Blue (reduces iron back to Fe2+)
  • Note: Methylene Blue is contraindicated in G6PD deficiency

Lead

Antidote: Chelation Therapy (Dimercaprol, EDTA, Succimer)

Toxidrome / Presentation

  • Children: Cognitive impairment, developmental delay, abdominal pain, constipation
  • Adults: Peripheral neuropathy (wrist/foot drop), abdominal colic, anemia
  • Basophilic stippling on blood smear
  • Burton's line (blue line on gums)

Management Steps

  • Remove from source of exposure
  • Oral Succimer for mild/moderate levels
  • IV EDTA and Dimercaprol for encephalopathy or very high levels

Isoniazid (INH)

Antidote: Pyridoxine (Vitamin B6)

Toxidrome / Presentation

  • Refractory seizures (status epilepticus)
  • High anion gap metabolic acidosis (due to seizing)
  • Coma

Management Steps

  • Administer IV Pyridoxine (repletes GABA by bypassing the INH block on pyridoxine kinase)
  • Benzodiazepines (though less effective without GABA available)

Valproic Acid

Antidote: L-Carnitine

Toxidrome / Presentation

  • CNS depression / Coma
  • Hyperammonemia (leading to encephalopathy)
  • Hepatotoxicity
  • Bone marrow suppression

Management Steps

  • Supportive care
  • L-Carnitine for patients with hyperammonemia, hepatotoxicity, or coma

Barbiturates

Antidote: None (Supportive)

Toxidrome / Presentation

  • Profound CNS depression / Coma
  • Respiratory depression
  • Hypotension
  • Hypothermia
  • Loss of corneal and deep tendon reflexes

Management Steps

  • Airway protection
  • Urine alkalinization for long-acting agents (Phenobarbital) to enhance elimination
  • Hemodialysis for severe cases

Neuroleptic Malignant Syndrome (NMS)

Antidote: Dantrolene, Bromocriptine

Toxidrome / Presentation

  • Hyperthermia (often extreme > 104F)
  • Severe 'lead-pipe' muscle rigidity
  • Autonomic instability
  • Altered mental status

Management Steps

  • Stop offending agent immediately
  • Aggressive cooling and IV fluids
  • Dantrolene (muscle relaxant) or Bromocriptine (dopamine agonist)

Phenytoin (Dilantin)

Antidote: None

Toxidrome / Presentation

  • Nystagmus (horizontal, then vertical in severe tox)
  • Ataxia
  • Slurred speech
  • Lethargy/Coma
  • Paradoxical seizures (rare)

Management Steps

  • Supportive care
  • Multi-dose activated charcoal (MDAC) can enhance elimination

Carbamazepine

Antidote: None

Toxidrome / Presentation

  • CNS depression
  • Ataxia, Nystagmus
  • Anticholinergic signs
  • Seizures, QRS prolongation

Management Steps

  • MDAC (undergoes enterohepatic recirculation)
  • Sodium bicarbonate if QRS prolonged
  • Hemodialysis in massive overdoses

Isopropyl Alcohol (Rubbing Alcohol)

Antidote: None

Toxidrome / Presentation

  • CNS depression (twice as intoxicating as ethanol)
  • Hemorrhagic gastritis (vomiting blood)
  • Fruity breath odor (acetone)

Management Steps

  • Supportive care
  • Hemodialysis for severe hemodynamic instability (rarely needed)
  • DO NOT use Fomepizole (isopropyl alcohol does not form toxic acid metabolites)

Arsenic

Antidote: Dimercaprol (BAL), Succimer (DMSA)

Toxidrome / Presentation

  • Acute: Severe 'rice-water' cholera-like diarrhea, garlic breath, QTc prolongation
  • Chronic: Mees lines (white lines on nails), hyperkeratosis, neuropathy

Management Steps

  • Aggressive fluid resuscitation
  • Chelation therapy with Dimercaprol (IM) for severe/encephalopathy or Succimer (PO) for less severe

Mercury (Elemental and Inorganic)

Antidote: Dimercaprol, Succimer

Toxidrome / Presentation

  • Elemental (inhaled): Pneumonitis, noncardiogenic pulmonary edema
  • Inorganic (ingested): Caustic gastroenteritis, acute tubular necrosis
  • Acrodynia (Pink disease) in children

Management Steps

  • Chelation therapy
  • DO NOT use Dimercaprol for elemental/organic mercury (can increase brain levels) - use Succimer instead

Thallium

Antidote: Prussian Blue

Toxidrome / Presentation

  • Severe painful peripheral neuropathy
  • Alopecia (hair loss starts 2-3 weeks after ingestion)
  • Gastroenteritis (early)

Management Steps

  • Prussian Blue (potassium ferric hexacyanoferrate) binds thallium in the gut and interrupts enterohepatic circulation

Pit Viper Envenomation (Rattlesnakes, Copperheads, Cottonmouths)

Antidote: CroFab or Anavip (Antivenom)

Toxidrome / Presentation

  • Severe local tissue damage (swelling, pain, ecchymosis, blebs)
  • Systemic toxicity: Hypotension, metallic taste, fasciculations
  • Hematotoxicity: Thrombocytopenia, coagulopathy (DIC-like)

Management Steps

  • Immobilize limb at heart level
  • Administer antivenom if progressive swelling, systemic signs, or coagulopathy
  • Fasciotomy is rarely indicated (swelling is usually subcutaneous, not in the fascia)

Coral Snake Envenomation (Elapidae)

Antidote: Micrurus fulvius antivenom

Toxidrome / Presentation

  • Minimal local reaction
  • Delayed, progressive neurotoxicity (cranial nerve palsies, ptosis, bulbar weakness, respiratory failure)

Management Steps

  • Admit to ICU and monitor closely for respiratory failure
  • Give antivenom for ANY confirmed bite, even if asymptomatic (effects are irreversible once they start)

Black Widow Spider (Latrodectus)

Antidote: Latrodectus Antivenom (Rarely used)

Toxidrome / Presentation

  • Pinprick sensation followed by severe, cramping muscle pain (especially abdomen/back)
  • Rigid, board-like abdomen (mimics acute abdomen)
  • Hypertension, tachycardia, diaphoresis

Management Steps

  • Pain control (Opioids)
  • Muscle relaxants (Benzodiazepines)
  • Antivenom reserved for severe, refractory pain or high-risk patients (due to risk of anaphylaxis)

Brown Recluse Spider (Loxosceles)

Antidote: None

Toxidrome / Presentation

  • Painless bite initially
  • Develops into a painful 'red, white, and blue' sign (erythema, blanching, cyanosis)
  • Progresses to necrotic ulcer
  • Rarely: Systemic loxoscelism (hemolysis, DIC, renal failure)

Management Steps

  • Wound care, update tetanus
  • Surgical debridement ONLY after the lesion has fully demarcated and stopped spreading (weeks later)
  • Monitor for hemolysis

Bark Scorpion (Centruroides sculpturatus)

Antidote: Centruroides Antivenom (Anascorp)

Toxidrome / Presentation

  • Severe local pain without swelling (tap test positive)
  • Neuromuscular: Roving eye movements, fasciculations, muscle spasms
  • Autonomic: Hypersalivation, tachycardia

Management Steps

  • Benzodiazepines for muscle spasms
  • Atropine for severe oral secretions (especially in kids)
  • Antivenom for severe systemic symptoms

Ciguatera Fish Poisoning

Antidote: None (Mannitol historically, but evidence is weak)

Toxidrome / Presentation

  • Gastroenteritis (early)
  • Neurological: Hot/cold temperature reversal (pathognomonic), feeling of 'loose teeth', paresthesias
  • Cardiovascular: Bradycardia, hypotension

Management Steps

  • Supportive care
  • Atropine for severe bradycardia
  • Avoid fish, alcohol, and nuts for months (can trigger symptom relapse)

Scombroid Fish Poisoning (Histamine Toxicity)

Antidote: Antihistamines (H1 and H2 blockers)

Toxidrome / Presentation

  • Flushing, rash, headache, palpitations, diarrhea
  • Peppery or metallic taste to the fish
  • Mimics an allergic reaction

Management Steps

  • Diphenhydramine (H1) and Famotidine (H2)
  • Epinephrine for severe bronchospasm/hypotension (rare)

Tetrodotoxin (Pufferfish / Fugu)

Antidote: None

Toxidrome / Presentation

  • Perioral paresthesias (starts quickly)
  • Ascending paralysis
  • Respiratory failure while fully conscious
  • Hypotension

Management Steps

  • Aggressive supportive care
  • Intubation and mechanical ventilation until the toxin wears off (usually days)

Botulism (Clostridium botulinum)

Antidote: Botulinum Antitoxin (Heptavalent)

Toxidrome / Presentation

  • Descending, symmetric flaccid paralysis
  • Bulbar palsies (diplopia, dysarthria, dysphagia, ptosis)
  • Clear sensorium (no mental status changes)

Management Steps

  • Intubation for respiratory failure
  • Administer antitoxin immediately (stops progression, does not reverse existing paralysis)
  • BabyBIG (Botulism Immune Globulin) for infant botulism

Amatoxin-Containing Mushrooms (Death Cap / Amanita phalloides)

Antidote: Silibinin (Milk Thistle extract), N-acetylcysteine (NAC)

Toxidrome / Presentation

  • Phase 1 (6-24h): Severe cholera-like diarrhea, vomiting
  • Phase 2 (24-48h): False recovery
  • Phase 3 (3-5 days): Fulminant hepatic and renal failure

Management Steps

  • Aggressive IV fluids
  • Penicillin G and Silibinin (inhibit transport into hepatocytes)
  • Liver transplant evaluation

Muscarine-Containing Mushrooms (Inocybe / Clitocybe species)

Antidote: Atropine

Toxidrome / Presentation

  • Rapid onset (30 mins - 2 hours)
  • SLUDGE syndrome: Salivation, Lacrimation, Urination, Defecation, GI cramping, Emesis
  • Bradycardia, miosis, wheezing

Management Steps

  • Atropine to reverse muscarinic effects (dry secretions, treat bradycardia)
  • Supportive care

Psilocybin (Magic Mushrooms)

Antidote: None

Toxidrome / Presentation

  • Hallucinations (visual/auditory), altered perception of time
  • Mydriasis, tachycardia, mild hypertension
  • Panic, anxiety

Management Steps

  • Quiet, dark room
  • Reassurance ('talk down')
  • Benzodiazepines for severe agitation or panic

Plant Cardiac Glycosides (Oleander, Foxglove, Lily of the Valley)

Antidote: Digoxin-specific antibody fragments (Digibind)

Toxidrome / Presentation

  • Identical to Digoxin toxicity
  • Nausea, vomiting, abdominal pain
  • Bradycardia, AV block, ventricular arrhythmias
  • Hyperkalemia

Management Steps

  • Give Digibind for severe arrhythmias or hyperkalemia
  • Avoid calcium for hyperkalemia management

Jimson Weed (Datura stramonium)

Antidote: Physostigmine (rarely used)

Toxidrome / Presentation

  • Classic anticholinergic toxidrome
  • Delirium, hallucinations, picking at the air
  • Mydriasis, dry skin, hyperthermia, tachycardia, urinary retention

Management Steps

  • Supportive care, cooling
  • Benzodiazepines for agitation
  • Physostigmine ONLY for severe, refractory agitation (requires continuous ECG monitoring)

Long-Acting Anticoagulant Rodenticides (Superwarfarins)

Antidote: Vitamin K1 (Phytonadione), Fresh Frozen Plasma (FFP), Prothrombin Complex Concentrate (PCC)

Toxidrome / Presentation

  • Bleeding diathesis (epistaxis, hematuria, GI bleed, intracranial hemorrhage)
  • Delayed onset (takes a few days to deplete vitamin K-dependent factors)

Management Steps

  • Oral high-dose Vitamin K1 for months (due to the very long half-life of the poison)
  • FFP or PCC for active, life-threatening bleeding

Strychnine

Antidote: None

Toxidrome / Presentation

  • Severe, generalized muscle spasms triggered by minimal stimuli (light, sound, touch)
  • Opisthotonus (arching of the back)
  • Patient remains fully conscious during spasms
  • Lactic acidosis, rhabdomyolysis

Management Steps

  • Minimize sensory stimulation (dark, quiet room)
  • Aggressive use of Benzodiazepines and Barbiturates
  • Neuromuscular blockade and intubation for severe cases

Paraquat (Herbicide)

Antidote: None

Toxidrome / Presentation

  • Caustic injury to mouth/throat
  • Progressive, irreversible pulmonary fibrosis and acute respiratory distress syndrome (ARDS) over days/weeks
  • Renal failure

Management Steps

  • Aggressive decontamination (Fuller's earth or activated charcoal)
  • AVOID supplemental oxygen unless PaO2 < 60 (oxygen exacerbates free radical damage in the lungs)

Glyphosate (Roundup)

Antidote: None

Toxidrome / Presentation

  • Primarily driven by the surfactant formulation, not the glyphosate itself
  • Gastroenteritis, oral ulcerations
  • Severe toxicity: Hypotension, metabolic acidosis, renal failure, pulmonary edema

Management Steps

  • Aggressive supportive care
  • IV fluids for hypotension
  • Hemodialysis if refractory renal failure

Organochlorines (DDT, Lindane)

Antidote: None

Toxidrome / Presentation

  • Neurotoxicity
  • Tremors, hyperreflexia, ataxia
  • Myoclonus, Seizures
  • Cardiac sensitization to catecholamines (arrhythmias)

Management Steps

  • Benzodiazepines for seizures
  • Decontamination (wash skin with soap and water)
  • Avoid exogenous epinephrine (can trigger fatal arrhythmias)

Pyrethrins / Pyrethroids (Insecticides)

Antidote: None

Toxidrome / Presentation

  • Generally low toxicity to humans
  • Skin contact: Paresthesias, burning, tingling (without erythema)
  • Ingestion/Inhalation: Hypersensitivity reactions, asthma exacerbation, rare seizures (in massive doses)

Management Steps

  • Wash skin with soap and water
  • Vitamin E oil topically for paresthesias
  • Supportive care

Hydrofluoric Acid (HF)

Antidote: Calcium Gluconate

Toxidrome / Presentation

  • Severe, out-of-proportion deep tissue pain
  • Skin may look deceptively normal initially
  • Systemic: Profound Hypocalcemia, Hypomagnesemia, Hyperkalemia, fatal ventricular arrhythmias

Management Steps

  • Topical Calcium Gluconate gel massaged into the burn
  • Subcutaneous injection or regional intra-arterial infusion of Calcium Gluconate for deep/refractory pain
  • Aggressive IV Calcium for systemic toxicity

Caustics (Acids)

Antidote: None

Toxidrome / Presentation

  • Coagulation necrosis (forms a protective eschar that limits deep penetration)
  • Severe pain in mouth/throat, dysphagia
  • Gastric injury > Esophageal injury (acids pass through esophagus quickly and pool in the stomach)

Management Steps

  • Airway protection
  • DO NOT induce vomiting. DO NOT neutralize with alkalis. DO NOT give activated charcoal.
  • NPO, IV fluids

Caustics (Alkalis - Lye, Drain Cleaners, Button Batteries)

Antidote: None

Toxidrome / Presentation

  • Liquefaction necrosis (dissolves tissues, causing deep, penetrating, transmural injury)
  • Severe pain, drooling, dysphagia
  • Esophageal injury > Gastric injury (highly likely to cause esophageal perforation)

Management Steps

  • Airway protection
  • Immediate removal of button batteries lodged in the esophagus (can burn through in < 2 hours)
  • DO NOT induce vomiting or neutralize.

Hydrocarbons (Gasoline, Kerosene, Lamp Oil)

Antidote: None

Toxidrome / Presentation

  • High risk of aspiration pneumonitis (especially low viscosity/high volatility agents)
  • Choking, coughing, gagging
  • Hypoxia, ARDS
  • CNS depression
  • Cardiac sensitization (sudden sniffing death syndrome)

Management Steps

  • DO NOT induce vomiting (increases aspiration risk). DO NOT use activated charcoal.
  • Supportive respiratory care
  • Observe for 6 hours if asymptomatic

Camphor (Vicks VapoRub, Tiger Balm)

Antidote: None

Toxidrome / Presentation

  • Rapid onset of abrupt, refractory seizures (often the first symptom without warning)
  • Nausea, vomiting, feeling of warmth
  • Smell of camphor

Management Steps

  • Benzodiazepines for seizures
  • Supportive care
  • Avoid emesis

Mothballs (Naphthalene)

Antidote: Methylene Blue (for Methemoglobinemia, but CAUTION: contraindicated if G6PD deficient)

Toxidrome / Presentation

  • Hemolysis and Methemoglobinemia (especially in G6PD deficiency)
  • Nausea, vomiting, abdominal pain
  • Jaundice, hemoglobinuria

Management Steps

  • Supportive care
  • Blood transfusions for severe hemolysis

Mothballs (Paradichlorobenzene)

Antidote: None

Toxidrome / Presentation

  • Generally much less toxic than naphthalene
  • Nausea, vomiting
  • Mild CNS depression

Management Steps

  • Supportive care

Local Anesthetic Systemic Toxicity (LAST - Bupivacaine, Lidocaine)

Antidote: Intravenous Lipid Emulsion (Intralipid 20%)

Toxidrome / Presentation

  • CNS Phase: Tinnitus, perioral numbness, metallic taste, agitation, progressing to seizures
  • Cardiovascular Phase: Hypertension/Tachycardia progressing to profound hypotension, bradycardia, wide QRS, asystole

Management Steps

  • Stop injection immediately
  • Airway management, Benzodiazepines for seizures
  • Administer Intralipid 20% bolus followed by infusion ('lipid sink' pulls anesthetic out of tissues)

Inhalants (Nitrous Oxide / 'Whippits')

Antidote: None

Toxidrome / Presentation

  • Acute: Euphoria, giggling, dizziness, hypoxia
  • Chronic: Irreversible Vitamin B12 inactivation leading to subacute combined degeneration of the spinal cord (peripheral neuropathy, ataxia, myelopathy)

Management Steps

  • Abstinence
  • High-dose Vitamin B12 supplementation (often IM)

Inhalants (Toluene / Glue Sniffing)

Antidote: None

Toxidrome / Presentation

  • Acute: CNS depression, hallucinations, cardiac arrhythmias
  • Chronic: 'Glue sniffer's encephalopathy' (dementia, ataxia, white matter changes)
  • Severe hypokalemia, non-anion gap metabolic acidosis (Type 1 RTA)

Management Steps

  • Aggressive potassium replacement
  • Supportive care

GHB (Gamma-Hydroxybutyrate / 'Liquid Ecstasy')

Antidote: None

Toxidrome / Presentation

  • Abrupt onset of deep coma, often with respiratory depression and bradycardia
  • Rapid, spontaneous recovery upon awakening ('flipping a switch')
  • Agitation/combativeness during intubation/emergence

Management Steps

  • Airway protection (intubation often required but short-lived)
  • Atropine for severe bradycardia
  • Supportive care

Synthetic Cannabinoids (Spice, K2)

Antidote: None

Toxidrome / Presentation

  • Unlike natural cannabis: Agitation, aggression, acute psychosis
  • Tachycardia, hypertension, diaphoresis
  • Seizures, acute kidney injury

Management Steps

  • Aggressive sedation with Benzodiazepines
  • Avoid physical restraints if possible (rhabdomyolysis risk)

Synthetic Cathinones (Bath Salts, Flakka)

Antidote: None

Toxidrome / Presentation

  • Excited delirium syndrome: Extreme agitation, paranoia, superhuman strength, violence
  • Severe hyperthermia, tachycardia
  • Rhabdomyolysis

Management Steps

  • Massive doses of Benzodiazepines or Antipsychotics for behavioral control
  • Aggressive cooling for hyperthermia
  • IV fluids for rhabdo

LSD (Lysergic Acid Diethylamide)

Antidote: None

Toxidrome / Presentation

  • Visual/auditory hallucinations, synesthesia (seeing sounds)
  • Mydriasis, mild tachycardia, hypertension
  • Anxiety, panic attacks ('bad trip')

Management Steps

  • Place in a quiet, dark environment
  • Reassurance
  • Benzodiazepines for severe anxiety/panic

PCP (Phencyclidine)

Antidote: None

Toxidrome / Presentation

  • Dissociative state, extreme agitation, violent behavior, pain insensitivity
  • Rotary or multidirectional nystagmus (classic sign)
  • Hypertension, tachycardia, muscle rigidity

Management Steps

  • Benzodiazepines (high doses often needed)
  • Physical restraints + chemical sedation
  • Monitor for rhabdomyolysis and trauma

MDMA (Ecstasy, Molly)

Antidote: None (Cyproheptadine if severe serotonin syndrome)

Toxidrome / Presentation

  • Euphoria, empathy, increased energy
  • Bruxism (teeth grinding)
  • Severe toxicity: Serotonin syndrome, hyperthermia, hyponatremia (due to ADH secretion + excessive water drinking)

Management Steps

  • Cooling for hyperthermia
  • Fluid restriction or Hypertonic saline (3%) if severe symptomatic hyponatremia causing seizures

Monoamine Oxidase Inhibitors (MAOIs)

Antidote: Phentolamine (for hypertensive crisis)

Toxidrome / Presentation

  • Overdose: Delayed onset (12-24h) of hyperthermia, tachycardia, rigidity, seizures
  • Tyramine Reaction: Severe hypertensive crisis after eating aged cheese, cured meats, or wine

Management Steps

  • Phentolamine or Nitroprusside for hypertension
  • Cooling for hyperthermia
  • Benzodiazepines for seizures

Clonidine

Antidote: Naloxone (Inconsistent efficacy)

Toxidrome / Presentation

  • Mimics opioid overdose: Miosis (pinpoint pupils), CNS depression, respiratory depression
  • Bradycardia, hypotension
  • Often seen in pediatric accidental ingestions (very toxic in small doses)

Management Steps

  • Naloxone (high doses, e.g., 2-4 mg, occasionally reverses symptoms, mechanism unknown)
  • Atropine for bradycardia
  • Vasopressors/Fluids for hypotension

Loperamide (Imodium) - Massive Overdose

Antidote: Naloxone

Toxidrome / Presentation

  • Opioid toxidrome: CNS and respiratory depression
  • Cardiotoxicity (The 'Poor Man's Methadone'): Massive QTc prolongation, Torsades de Pointes, ventricular arrhythmias, cardiac arrest

Management Steps

  • Naloxone for respiratory depression
  • Magnesium Sulfate for Torsades de Pointes
  • Overdrive pacing or Isoproterenol for refractory Torsades

Colchicine

Antidote: None (Colchicine-specific Fab fragments exist but are not commercially available)

Toxidrome / Presentation

  • Phase 1 (< 24h): Severe N/V/D (cholera-like)
  • Phase 2 (2-7 days): Multi-organ failure, bone marrow suppression, ARDS, arrhythmias, alopecia
  • Phase 3 (> 7 days): Rebound leukocytosis, recovery

Management Steps

  • Aggressive supportive care
  • Gastric lavage or multi-dose activated charcoal if presenting very early
  • High mortality in massive overdoses

Absinthe (Thujone)

Antidote: None

Toxidrome / Presentation

  • GABA antagonist leading to central nervous system excitation
  • Restlessness, hallucinations, tremors
  • Refractory seizures

Management Steps

  • Benzodiazepines for seizures and agitation
  • Supportive care

Aconite (Monkshood / Wolfsbane)

Antidote: Amiodarone (historically used, but often refractory to standard ACLS)

Toxidrome / Presentation

  • Opens sodium channels causing persistent depolarization
  • Perioral numbness, tingling in limbs
  • Severe ventricular arrhythmias (V-tach, V-fib), hypotension

Management Steps

  • Charcoal hemoperfusion if severe
  • ECMO for refractory cardiogenic shock or arrhythmias

Amanita muscaria (Ibotenic acid / Muscimol)

Antidote: None

Toxidrome / Presentation

  • Ibotenic acid (glutamate agonist): Agitation, hallucinations, seizures
  • Muscimol (GABA agonist): CNS depression, coma
  • Often alternates between excitation and depression

Management Steps

  • Supportive care
  • Benzodiazepines for agitation and seizures

Amitraz (Tick Dip / Veterinary Insecticide)

Antidote: Yohimbine or Atipamezole (Alpha-2 antagonists, but rarely used in humans)

Toxidrome / Presentation

  • Alpha-2 adrenergic agonist (mimics clonidine)
  • Profound CNS depression, bradycardia, hypotension
  • Hyperglycemia (classic distinguishing feature from clonidine)

Management Steps

  • Supportive care
  • Atropine for severe bradycardia
  • Vasopressors for hypotension

Warfarin

Antidote: Vitamin K1 (Phytonadione), Prothrombin Complex Concentrate (PCC)

Toxidrome / Presentation

  • Bleeding diathesis (epistaxis, GI bleeding, hematuria, intracranial hemorrhage)
  • Bruising

Management Steps

  • Hold Warfarin for mild INR elevation without bleeding
  • Oral/IV Vitamin K for high INR without active bleeding
  • PCC + IV Vitamin K for life-threatening bleeding

Baclofen

Antidote: None

Toxidrome / Presentation

  • GABA-B agonist
  • Profound CNS depression, coma
  • Respiratory depression
  • Paradoxical seizures (especially during withdrawal)

Management Steps

  • Airway protection and intubation
  • Benzodiazepines for seizures
  • Supportive care (patients often require prolonged ventilation)

Barium (Soluble salts - NOT contrast medium)

Antidote: None

Toxidrome / Presentation

  • Blocks potassium channels (preventing K+ from exiting cells) leading to profound, life-threatening Hypokalemia
  • Progressive ascending flaccid paralysis
  • Ventricular arrhythmias

Management Steps

  • Massive IV potassium replacement (often requires central line due to high concentrations needed)
  • Monitor ECG continuously

Chloral Hydrate ('Mickey Finn')

Antidote: None

Toxidrome / Presentation

  • Deep CNS depression, coma
  • Pear-like odor on breath
  • Cardiac arrhythmias (sensitizes myocardium to catecholamines)

Management Steps

  • Avoid epinephrine/isoproterenol (can trigger fatal arrhythmias)
  • Propranolol or Esmolol for ventricular arrhythmias

Chloroquine / Hydroxychloroquine

Antidote: High-Dose Diazepam (mechanism unknown, but cardioprotective)

Toxidrome / Presentation

  • Rapid onset (within 1-3 hours) of cardiogenic shock and cardiac arrest
  • QRS widening, prolonged QTc
  • Hypokalemia (due to intracellular shift, severity correlates with mortality)

Management Steps

  • Early intubation
  • Epinephrine for shock
  • High-dose Diazepam infusion
  • DO NOT aggressively replete potassium (it will shift back out and cause hyperkalemia later)

Water Hemlock (Cicutoxin)

Antidote: None

Toxidrome / Presentation

  • Most toxic indigenous plant in North America
  • Potent non-competitive GABA antagonist
  • Rapid onset of refractory status epilepticus
  • Rhabdomyolysis, metabolic acidosis

Management Steps

  • Aggressive airway control and intubation
  • Massive doses of Benzodiazepines and Barbiturates
  • Propofol infusion for refractory seizures

Dapsone

Antidote: Methylene Blue, Cimetidine

Toxidrome / Presentation

  • Profound Methemoglobinemia (chocolate-brown blood, cyanosis)
  • Hemolytic anemia (especially in G6PD deficiency)
  • Sulfhemoglobinemia (causes green-tinged blood, cannot be treated)

Management Steps

  • Methylene Blue for Methemoglobinemia (unless G6PD deficient)
  • Cimetidine (inhibits CYP450 metabolism to the toxic hydroxylamine metabolite)

Dextromethorphan (DXM / 'Robo-tripping')

Antidote: Naloxone (Inconsistent)

Toxidrome / Presentation

  • Dissociative state, hallucinations (acts at NMDA receptors like PCP/Ketamine)
  • Serotonin syndrome (tachycardia, clonus, diaphoresis)
  • Lethargy or coma in massive doses

Management Steps

  • Supportive care
  • Benzodiazepines for agitation or seizures
  • Cooling for hyperthermia

Diquat (Herbicide)

Antidote: None

Toxidrome / Presentation

  • Unlike paraquat, DOES NOT concentrate in the lungs
  • Severe gastroenteritis, caustic injury
  • Acute renal failure, toxic encephalopathy, seizures

Management Steps

  • Aggressive fluid resuscitation
  • Activated charcoal
  • Supportive care

Ergotamine (Ergotism)

Antidote: Nitroprusside, Phentolamine

Toxidrome / Presentation

  • Profound peripheral vasoconstriction (St. Anthony's Fire)
  • Ischemia/gangrene of fingers, toes, and bowel
  • Headache, nausea, vomiting
  • Often triggered by co-ingestion with CYP3A4 inhibitors (e.g., macrolides)

Management Steps

  • Vasodilators (Nitroprusside or Nitroglycerin)
  • Heparin to prevent thrombosis in stagnant vessels

Formaldehyde

Antidote: Fomepizole (if ingested as methanol, but usually ineffective if already metabolized to formate), Folinic Acid

Toxidrome / Presentation

  • Caustic injury to GI tract
  • Metabolized to formic acid causing severe high anion gap metabolic acidosis
  • Visual toxicity (similar to methanol)

Management Steps

  • Folinic acid (Leucovorin) to enhance metabolism of formic acid
  • Hemodialysis for severe acidosis

Freon (Fluorocarbons)

Antidote: None

Toxidrome / Presentation

  • Inhalation ('huffing') causes euphoria, then CNS depression
  • Frostbite to lips/airway if inhaled directly from pressurized tank
  • Myocardial sensitization to catecholamines (Sudden Sniffing Death Syndrome)

Management Steps

  • Avoid physical exertion and exogenous epinephrine
  • Beta-blockers (Esmolol) for ventricular arrhythmias

Gyromitra (False Morel Mushroom)

Antidote: Pyridoxine (Vitamin B6)

Toxidrome / Presentation

  • Contains gyromitrin, metabolized to monomethylhydrazine (rocket fuel)
  • Depletes Vitamin B6 leading to refractory seizures
  • Hepatotoxicity and hemolysis (rarely)

Management Steps

  • High-dose IV Pyridoxine to treat seizures (bypasses GABA depletion)

Hydrogen Sulfide (H2S / 'Sewer Gas' / 'Knockdown Gas')

Antidote: Sodium Nitrite

Toxidrome / Presentation

  • Rotten egg odor (causes olfactory fatigue at high concentrations so you stop smelling it)
  • Potent cellular asphyxiant (inhibits cytochrome oxidase like cyanide)
  • Sudden collapse ('knockdown')
  • Pulmonary edema

Management Steps

  • Remove from environment immediately
  • 100% Oxygen
  • Sodium Nitrite (induces methemoglobinemia which binds the sulfide) - DO NOT use sodium thiosulfate (useless for H2S)

Hexachlorophene (Antiseptic)

Antidote: None

Toxidrome / Presentation

  • Neurotoxicity, spongy degeneration of white matter
  • Confusion, lethargy, seizures, and cerebral edema
  • Historically seen in premature infants bathed in it

Management Steps

  • Discontinue use
  • Supportive care for cerebral edema and seizures

Hydrogen Peroxide (High Concentration >10%)

Antidote: Hyperbaric Oxygen (HBO)

Toxidrome / Presentation

  • Liberates massive amounts of oxygen gas
  • Gastric distension, viscous perforation
  • Portal venous gas, systemic gas emboli (stroke, myocardial infarction)

Management Steps

  • Immediate HBO therapy for suspected gas embolism
  • Surgical evaluation for viscus perforation

Ipecac (Emetine)

Antidote: None

Toxidrome / Presentation

  • Chronic abuse (eating disorders) causes accumulation in muscle
  • Severe reversible cardiomyopathy, congestive heart failure
  • Myopathy, muscle weakness

Management Steps

  • Discontinue use
  • Supportive care for heart failure (often fully recovers over months)

Kava Kava

Antidote: None

Toxidrome / Presentation

  • Sedation, euphoria
  • Hepatotoxicity (can lead to fulminant liver failure)
  • Kava dermopathy (scaly, yellow skin rash in chronic users)

Management Steps

  • Discontinue use
  • Evaluate for liver transplantation if fulminant failure occurs

Ketamine

Antidote: None

Toxidrome / Presentation

  • Dissociative anesthesia, 'K-hole'
  • Tachycardia, hypertension, increased secretions
  • Rotary nystagmus
  • Chronic use: Severe ulcerative cystitis (shrinking bladder)

Management Steps

  • Minimize sensory stimulation
  • Benzodiazepines for emergence delirium
  • Urology consult for chronic cystitis

Kratom (Mitragynine)

Antidote: Naloxone (for significant respiratory depression)

Toxidrome / Presentation

  • Low dose: Stimulant effects
  • High dose: Opioid-like effects (CNS/respiratory depression)
  • Seizures, intrahepatic cholestasis (jaundice)

Management Steps

  • Naloxone
  • Supportive care
  • Benzodiazepines for seizures

Methadone

Antidote: Naloxone

Toxidrome / Presentation

  • Profound and exceptionally prolonged opioid toxidrome (half-life up to 120 hours)
  • QTc prolongation and Torsades de Pointes

Management Steps

  • Continuous Naloxone infusion usually required due to long half-life
  • Magnesium for Torsades

Methotrexate

Antidote: Leucovorin (Folinic Acid), Glucarpidase

Toxidrome / Presentation

  • Bone marrow suppression (pancytopenia)
  • Severe mucositis, stomatitis, GI ulceration
  • Hepatotoxicity, nephrotoxicity (crystal nephropathy)

Management Steps

  • High-dose Leucovorin 'rescue' (bypasses folate antagonism)
  • Urine alkalinization
  • Glucarpidase (rapidly clears MTX from blood in renal failure)

Niacin (Vitamin B3 / Nicotinic Acid)

Antidote: None

Toxidrome / Presentation

  • Intense cutaneous flushing, pruritus, warmth (due to prostaglandin release)
  • Hepatotoxicity (especially sustained-release forms)
  • Hyperglycemia, hyperuricemia

Management Steps

  • Aspirin or NSAIDs to block prostaglandin-mediated flushing
  • Supportive care

Nutmeg (Myristicin)

Antidote: None

Toxidrome / Presentation

  • Anticholinergic-like symptoms (tachycardia, dry mouth, flushing)
  • Hallucinations, feelings of impending doom, paranoia
  • Nausea, vomiting

Management Steps

  • Supportive care
  • Benzodiazepines for severe anxiety or agitation

Pennyroyal Oil

Antidote: N-acetylcysteine (NAC)

Toxidrome / Presentation

  • Contains pulegone (metabolized to hepatotoxic menthofuran)
  • Severe hepatotoxicity (massive centrilobular necrosis similar to acetaminophen)
  • Seizures, coagulopathy

Management Steps

  • Administer NAC (mechanism is theoretically similar to APAP toxicity)
  • Supportive care for liver failure

Phenol (Carbolic Acid)

Antidote: Polyethylene Glycol (PEG) for dermal decontamination

Toxidrome / Presentation

  • Rapid absorption through intact skin
  • Severe systemic toxicity: Seizures, coma, cardiovascular collapse, arrhythmias
  • Local coagulation necrosis (painless white eschar)

Management Steps

  • Immediate removal of clothes and wipe skin with 50% PEG or copious water (water is less effective as phenol is poorly water-soluble)
  • Aggressive systemic support

Aluminum Phosphide / Zinc Phosphide (Fumigants)

Antidote: None

Toxidrome / Presentation

  • Releases phosphine gas upon contact with stomach acid/moisture
  • Rotten fish/garlic odor
  • Profound cardiogenic shock, severe metabolic acidosis, ARDS
  • Extremely high mortality

Management Steps

  • Intubation, aggressive vasopressors/inotropes
  • ECMO
  • DO NOT give water orally (increases gas production)

Pokeweed (Phytolacca americana)

Antidote: None

Toxidrome / Presentation

  • Severe hemorrhagic gastroenteritis
  • Nausea, vomiting, diarrhea (can cause severe dehydration/shock)
  • Bradycardia, respiratory depression in severe cases

Management Steps

  • Aggressive IV fluid resuscitation
  • Anti-emetics

Propofol Infusion Syndrome (PRIS)

Antidote: None

Toxidrome / Presentation

  • Occurs with prolonged, high-dose infusions
  • Severe metabolic acidosis, rhabdomyolysis, hyperkalemia
  • Hepatomegaly, lipemia
  • Refractory bradycardia progressing to asystole

Management Steps

  • STOP propofol immediately
  • Aggressive pacing and inotropes for bradycardia/shock
  • Hemodialysis or CRRT to clear toxic metabolites

Quetiapine (Seroquel)

Antidote: None

Toxidrome / Presentation

  • CNS depression, lethargy, coma
  • Tachycardia, mild hypotension
  • QTc prolongation (usually mild compared to others)

Management Steps

  • Supportive care
  • IV fluids for hypotension

Ricin (Castor Beans)

Antidote: None

Toxidrome / Presentation

  • Inhibits 60S ribosomal subunit (halts protein synthesis)
  • Ingestion: Severe hemorrhagic gastroenteritis, hepatic/renal failure
  • Inhalation: Severe ARDS, pulmonary edema, respiratory failure (often weaponized)

Management Steps

  • Aggressive supportive care
  • Fluid resuscitation

Salvia divinorum

Antidote: None

Toxidrome / Presentation

  • Potent Kappa-opioid receptor agonist
  • Intense, extremely short-lived hallucinations (5-15 mins if smoked)
  • Dysphoria, loss of motor control, uncontrollable laughter

Management Steps

  • Quiet room, reassurance (usually wears off before reaching the hospital)

Sildenafil (PDE-5 Inhibitors)

Antidote: None

Toxidrome / Presentation

  • Hypotension, reflex tachycardia
  • Flushing, headache
  • Blue-tinted vision (cyanopsia) due to PDE-6 crossover
  • Priapism

Management Steps

  • Vasopressors (Phenylephrine) for refractory hypotension
  • ABSOLUTELY CONTRAINDICATED to give nitrates
  • Aspirate corpora or inject phenylephrine for priapism > 4 hours

Silver (Argyria)

Antidote: None

Toxidrome / Presentation

  • Irreversible blue-gray discoloration of the skin and mucous membranes
  • Caused by chronic ingestion of colloidal silver (often for pseudoscientific health reasons)
  • Generally lacks systemic toxicity

Management Steps

  • Discontinue use (discoloration is permanent)

Boric Acid (Roach-killer / Antiseptic)

Antidote: None

Toxidrome / Presentation

  • 'Boiled lobster' appearance (intense generalized erythroderma)
  • Blue-green emesis/diarrhea
  • Seizures, renal failure, cardiovascular collapse (in massive pediatric ingestions)

Management Steps

  • Hemodialysis in massive overdoses or anuric renal failure
  • Supportive care

Bismuth (Pepto-Bismol)

Antidote: Dimercaprol (for Bismuth encephalopathy, rare)

Toxidrome / Presentation

  • Chronic toxicity: Reversible encephalopathy, myoclonus, ataxia
  • Dark stool, black tongue (normal side effect, not toxic)
  • Salicylate toxicity can occur from the subsalicylate component

Management Steps

  • Discontinue use
  • Treat concomitant salicylate toxicity if present

Benzene

Antidote: None

Toxidrome / Presentation

  • Acute: CNS depression, euphoria, cardiac arrhythmias
  • Chronic: Bone marrow suppression, Aplastic anemia, Acute Myeloid Leukemia (AML)

Management Steps

  • Remove from exposure
  • Hematology/Oncology referral for chronic exposure

Manganese

Antidote: None (Chelation is generally ineffective)

Toxidrome / Presentation

  • Occupational exposure (welders, miners)
  • Manganism: Irreversible Parkinsonian syndrome (bradykinesia, rigidity, dystonia, 'cock-walk' gait)
  • Psychiatric symptoms ('Manganese madness')

Management Steps

  • Remove from exposure
  • Levodopa (usually ineffective, unlike true Parkinson's)

Metaldehyde (Snail and Slug Bait)

Antidote: None

Toxidrome / Presentation

  • Primarily affects pets (dogs), but occasional human pediatric ingestion
  • Rapid onset of refractory seizures, severe muscle tremors ('shake and bake' syndrome), hyperthermia
  • Metabolic acidosis

Management Steps

  • Benzodiazepines and Barbiturates for seizures
  • Cooling for hyperthermia

Ethylene Oxide (Gas sterilant)

Antidote: None

Toxidrome / Presentation

  • Irritation to eyes/respiratory tract
  • Nausea, vomiting, delayed neurotoxicity (peripheral neuropathy, cognitive impairment)
  • Known human carcinogen

Management Steps

  • Supportive care
  • Remove from exposure

Amoxapine (Atypical Antidepressant)

Antidote: None

Toxidrome / Presentation

  • High incidence of seizures (often refractory) and status epilepticus
  • Less cardiovascular toxicity than classic TCAs
  • Renal failure secondary to rhabdomyolysis from seizures

Management Steps

  • Aggressive seizure control with Benzodiazepines
  • DO NOT use physostigmine

Carfentanil / High-Potency Synthetic Opioids

Antidote: Naloxone (Massive doses)

Toxidrome / Presentation

  • Extreme opioid toxicity
  • Profound respiratory depression/apnea, rapid onset of coma, wooden chest syndrome (severe chest wall rigidity preventing ventilation)

Management Steps

  • Requires massive, repeated doses of Naloxone (e.g., 10 mg or more)
  • Neuromuscular blockade and intubation for 'wooden chest' if Naloxone fails to reverse it

Iodine / Lugol's Solution

Antidote: Starch / Milk

Toxidrome / Presentation

  • Caustic injury to GI tract (vomiting, abdominal pain, diarrhea)
  • Brown staining of oral mucosa/vomitus
  • Severe toxicity: Shock, delirium, renal failure

Management Steps

  • Give oral starch or milk (binds iodine to form a less toxic complex)
  • Supportive care
  • Sodium thiosulfate (converts iodine to iodide)

Loxapine

Antidote: None

Toxidrome / Presentation

  • Typical antipsychotic
  • High rate of seizures in overdose
  • Extrapyramidal symptoms (dystonia), CNS depression

Management Steps

  • Benzodiazepines for seizures
  • Benztropine or Diphenhydramine for dystonic reactions

Lantana camara (Unripe berries)

Antidote: None

Toxidrome / Presentation

  • Contains lantadene
  • Severe gastroenteritis, hemorrhagic diarrhea
  • Lethargy, ataxia, cyanosis, hepatic damage

Management Steps

  • Aggressive IV fluids
  • Supportive care

Colocynth (Bitter Apple / Citrullus colocynthis)

Antidote: None

Toxidrome / Presentation

  • Potent cathartic
  • Severe, bloody, watery diarrhea, abdominal colic
  • Dehydration, electrolyte disturbances, renal failure

Management Steps

  • Aggressive fluid and electrolyte replacement