EM · Toxicology and environmental emergencies (approach)
The toxidrome approach and the general management of the poisoned patient
Also known as Toxidromes · Poisoning approach · Poisoned patient management · Toxicological syndromes
The systematic recognition of the poisoning syndrome from the constellation of signs, and the general management of the poisoned patient. The seven toxidromes are covered in full — the anticholinergic (hot, dry, red, blind, mad), the cholinergic (SLUDGE from organophosphates and nerve agents), the sympathomimetic (cocaine, amphetamine, MDMA), the opioid, the sedative-hypnotic, the serotonin syndrome (clonus, hyperreflexia, hyperthermia), and the neuroleptic malignant syndrome. The general management follows — the ABCDE, decontamination (activated charcoal within one hour, whole bowel irrigation for iron, lithium and packets), enhanced elimination (haemodialysis for lithium, salicylate, metformin and the toxic alcohols), and the antidotes (naloxone, N-acetylcysteine, fomepizole, sodium bicarbonate, digoxin Fab) with drug doses. ACEM-primary, globally tagged.
Checked against its sources on 12 Sept 2026
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- Opioid poisoning and the opioid toxidrome (emergency department diagnosis and management)
- Tricyclic antidepressant poisoning (emergency department diagnosis and management)
- Paracetamol poisoning
- Salicylate poisoning
- Toxic alcohol poisoning (methanol and ethylene glycol)
- Carbon monoxide poisoning
- Acute agitation and rapid tranquillisation
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- Hyperthermia with rigidity is life-threatening — distinguish serotonin syndrome (clonus, hyperreflexia, serotonergic agent) from neuroleptic malignant syndrome (lead-pipe rigidity, hyporeflexia, antipsychotic) and cool, sedate and treat the cause, never give antipyretics alone
- Flumazenil is dangerous in the unknown or co-ingested overdose — it precipitates seizures and refractory status, especially with tricyclic antidepressants; reserve it for isolated iatrogenic benzodiazepine oversedation
- Activated charcoal given to the unprotected airway causes aspiration pneumonitis — intubate first or withhold; do not give it for lithium, iron, hydrocarbons, acids, alkalis or alcohols, which it does not adsorb
- A wide QRS in the tricyclic overdose is sodium-channel cardiotoxicity — give intravenous sodium bicarbonate 1 to 2 mmol per kilogram, not antiarrhythmics
- Methadone re-narcotises after a single naloxone dose — start a naloxone infusion at two-thirds of the wakeful bolus per hour
Meet the patient
A 24-year-old is wheeled in at 3am, found down in a nightclub toilet — GCS 8, respiratory rate 6, pinpoint pupils, a clutch of unidentifiable tablets in his pocket. The registrar reaches for the urine toxidrome screen; the consultant checks the glucose, opens the airway, and gives naloxone. The six-compartment exam that follows — not the screen — names the poison.[2]
The single question in this resuscitation bay is the question on every poisoning: which receptor is the poison driving, and what reverses it? Hold that question and the seven toxidromes, the decontamination rules, and the antidote doses all fall into place.[2]
References5ShowHide
- [1]Hüser C, Bethlehem C, Dünser MW, et al. Critical care management of the patient with pharmaceutical poisoning. Intensive Care Med, 2025.PMID 41222651
- [2]Parris MA, Calello DP Found Down: Approach to the Patient with an Unknown Poisoning. Emerg Med Clin North Am, 2022.PMID 35461619
- [3]Chyka PA, Seger D, Krenzelok EP, Vale JA. Position paper: Single-dose activated charcoal. Clin Toxicol (Phila), 2005.PMID 15822758
- [4]Thanacoody R, Caravati EM, Troutman B, et al. Position paper update: whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol (Phila), 2015.PMID 25511637
- [5]Levine M, Brooks DE, Truitt CA, et al. Toxicology in the ICU: Part 1: general overview and approach to treatment. Chest, 2011.PMID 21896525