5 Quick Tox Cases

Well I am just back from Sydney – SMACC2013.  It was heaps of fun, and I got to meet a lot of my FOAMy heroes, long time collaborators and heaps of you folk that read this.

SMACC will be slowly trickled out over the ether in the coming months so you can enjoy it all and see what you missed – don’t worry there is a SMACC2014 in Brisbane – watch this space.

I will do my best to let you know when and where the SMACC material is released – or you could just sign up to Twitter and follow the guys who put the whole shebang together.   OK enough ramble.

This week I am giving not 1, not 2…  but 5 cases in a single hit.   It is a toxidrome showdown.  Imagine you are in a medium-sized ED when these 5 characters all present.  Here is what I want form you for each case…

A)  Name the toxidrome (or specific drug if you can)

B)  Outline what specific investigation you might consider

C) Outline in a few words your specific management plan – assume the basics are done.

The prize will be love and respect, I might even be able to get you one of 

Say no more  screen-shot-2013-03-05-at-7-28-19-pm


OK, here they are 5 cases – a quick background, Obs, Exam, ECG – and being Broome – there are no bloods etc available for now…  carry on.


60 yo man with chronic depression, usually managed by GP. Presents with GCS 8/15 after a seizure at home. He looks flushed, with dry skin. pulse – 120 in ST, BP 140/100, dilated equal pupils and a normal neuro exam. ECG shows sinus tachy with borderline wide QRS complexes.

45 yo man with chronic BPAD, usually managed in community by the mental health team. Well controlled symptoms recently. He presents with vomiting and 3 days of diarrhoea – he is complaining of abdo cramps. He looks dry, with sluggish cap refill, he has normal pupils, GCS 15, a fine tremor and a normal ECG

30 yo woman with borderline PD, multiples ODs in the past. Presents with syncope, nausea and dyspnoea at rest. BP 80/40, pulse 38 brady. She has bibasal creps (and US Kerley Bs) Neuro exam shows myoclonus in the limbs. ECG shows a 2nd degree block with 3:1 conduction. Her BSL is 18 mmol

A usually healthy, happy 23 yo woman. Presents with agitation, feeling thirsty and anxious. She also reports diarrhoea. She has dilated pupils, temp = 37.7. She is sweaty with a pulse of 120/min. Neuro = 4 beats of clonus in the legs. ECG = sinus tachy

This is a 50 yo man with chronic schizophrenia on a community-treatment order. Receives a depot every 2 weeks. HE is brought in as he is mute, staring and has developed incontinence. Pulse= 110, BP 160/110, temp = 38.8 He is sweaty, pale and drooling. Neuro shows increased tone, but blunted reflexes. ECG is normal



  1. hello might give this a shot. i got some help from LITFL and my pharmacology textbooks.

    Case #1
    A.?TCA overdose (older chap+seizure : + dilated pupils suggest an anticholinergic, widened QRS +tachycardia suggests something cardiac toxic)
    B. a bedside VBG to assess acidosis/CO2/Bicarb
    C. resuscitate with intubation for airway protection/controlling ventilation to help acidosis
    bicarb infusion
    magnesium in case he goes to torsades

    Case #2
    BPAD suggests antimanic treatment
    A. Lithium
    B.Lithium level
    C. assess cause ? chicken vs egg – – did he have a concurrent illness i.e. prerenal ARF from gastro leading to this
    mainstays include IV rehydration
    consider dialysis if neurological deterioration

    Case #3
    A. beta/CCB blocker – ? propranol
    C. if GCS deteriorating or seizures, intubate.
    fluid resuscitation for hypotension.
    atropine +- adrenaline infusion for ongoing brady + hypo.
    glucagon ??

    A. anticholinergic (from ? antihistamines)
    B. bHCG/U+Es/Creat/VBG
    C. IV rehydration

    Case #5
    A. Serotonin syndrome+ Neuroleptic malignant syndrome
    B. Full septic screen (BC.FBC.U+Es/LFTs/Serum Paracetamol/VBG) CXR CT Head
    C. sweaty/pale/drooling – looks sick
    intubate ? I quote : from LITFL

    truncal rigidity impeding ventilation
    hyperthermia (T39.5C+)
    rising PaCO2
    rising CK

    (only seen one case at the PA as a lowly resident where the boss says “screw the clonus”, “he’s sick mate!” —the patient despite bein GCS 13 and agitated breathing on his own had a CO2 of 70!)
    benzos and IV rehydration

  2. Bryan Hayes says

    1) TCA; monitor ECG for QRS width, vitals; treat with sodium bicarbonate for QRS > 100 msec, norepinephrine for hypotension, IV fat emulsion

    2) Lithium; monitor lithium level, renal function, urine output; treat with fluids

    3) calcium channel blockers inhibit calcium channels in pancreas also, causes decreased insulin release; monitor vitals; treats with fluids, calcium, high dose insulin, norepinephrine, possibly glucagon, IV fat emulsion, even ECMO if needed

    4) serotonin syndrome; treat with fluids, benzodiazepines, and possibly cyproheptidine

    5) NMS; treat with fluids, benzodiazepines, possibly bromocriptine, possibly dantrolene

  3. Minh Le Cong says

    Case 5 = neuroleptic malignant syndrome. check CK/LFTs, supportive care, dantrolene/bromocriptine
    Case 4= stimulant syndrome , supportive care, sedation/benzos
    Case 3= CCB overdose verapamil or diltiazem in Oz, supportive care, Ca++, glucagon, insulin /dextrose infusion
    Case 2= serotonergic syndrome , supportive care, withdraw inducing agent, check CK/LFTs, cyproheptadine
    Case 1 = anticholinergic syndrome/TCA OD with Na channel blocking effect , supportive care, NaHCO3 iv.

  4. Matthew Oliver says

    With a little help from my Toxicology mate Dr Jon Brett:-
    A. Likely TCA OD (Anticholinergic Syn)
    B. VBG, Electrolytes
    C. RSI, Hyperventilate, Bicarb, bicarb and more Bicarb. If that fails Lidnocaine (see latest EM:RAP episode)

    Case 2-
    A. Lithium
    B. Lithium level, VBG, Electrolytes and renal function
    C. Aggresively Hydrate with NaCl, re-check Li+ level in 6hrs. Possible dialysis depending on level, seizures and haemodynamics

    Case 3-
    A. Calcium Channel blocker. ?Verapamil
    B. Calcium levels
    C. 10mls of 10% Calcium gluconate until resolution of HB and improvements in haemodynamics, Norad (or adrenaline boluses) infusion, Insulin thearpy (1U/kg bolus followed by 0.5U/kg/hr infusion). Glucose is optional and controversial but some say may guide therapy without glucose

    Case 4-
    A. Serotonin Syndrome
    B. Check B-HCG, Septic screen, R/o other causes etc.
    C. Fluids, Benzo’s (Chlorpromazine or Cyproheptadine if altered conscious level)

    Case 5-
    A. Neuroleptic Malignant Syndrome
    B. Septic Screen
    C. Bromocriptine, or if life threatening features arise… ECT

  5. John Cronin (@croninjj) says

    Hey Casey

    Thanks for the cases. We discussed them at registrar teaching in our shop today and came up with our group response. Thanks to Alma, Ayda, Eimear, Will, Zsolt and especially our consultant Nigel Salter. Here goes:

    Tricyclic overdose
    Blood gas to check pH
    ECG you already commented on, but QRS widening and specifically the size of the RS interval is the best predictor of toxicity, and therefore likelihood of seizures and cardiac arrest
    Bicarbonate therapy.
    *Don’t give phenytoin for seizures as it also blocks Na channels and could therefore increase the likelihood of arrest. Same goes for the use of Amiodarone.

    Lithium levels
    Fluids +/- diuresis

    Beta-blocker overdose.
    *Ca channel blocker is also a possibility.
    Potassium level
    Glucagon (although likely to need lots of). Insulin and dextrose infusion also an option. Difficult o treat with Adrenaline as all the receptors are blocked, so it’s like trying to flog a dead horse!

    CK – risk of rhabdomyolysis
    +/- benzo

    Neuroleptic Malignant Syndrome
    CK (again); septic screen important
    Hydration +/- benzo
    Dantrolene more for malignant hyperthermia, also likely to need lots of it and at 38.8 this patient’s temp is not really high enough to indicate it.

    • Hi John
      Thanks for the feedback – great to hear the material is useful out there. Actually I ran this in my group before posting it.
      Please have a listen to the podcast – some great pearls from Bryan Hayes

  6. #1 TCA OD. Send acetaminophen and aspirin levels. Usual septic w/up for hot and altered. Try to find out the time last seen normal or potential time of ingestion. Consider decon. Tube and bicarbonate, bicarbonate, bicarbonate until QRS narrows and then bicarb infusion. Monitor blood gases, pH, K.
    Do not give physostigmine because it makes their ECG look like this ____________ Seizure with TCA OD = bad. Usually closely followed by cardiovascular collapse. Use midazolam if recurrent seizures. Disposition = ICU
    #2. Lithium toxicity. Send levels and the usual, including electrolytes and renal function. Find out if there was large acute ingestion or recent change in dose. Find out if he start taking any new meds that may addected his kisnays. For trratment fluids to get him to eucolemia. If the levels are really high or his kidneys are pooped, dialysis is the best option. And stop his Lithium for a while perhaps?
    #3. This lovely lady overdosed on CCB. Not a nice thing to do. Get acetaminophen, ASA, beta, get the usuals and extended lytes with Ca, Mg levels. Tube and decon if recent ingestion or extended release. Do whole bowel via OG. Place pads on her for good luck. Give her little bolus to make sure her tank is full because she is in for along ride. Atropine, calcium IV, start her on norepinephrine. Titrate up, add another. Think of milrinone as some people reported success with combination of these. High dose insulin bolus 1u/kg please give it with D50, follow with infusion at 1/u/kg/hr with D5W. Monitor glucose. Glucagon and then more of it with antiemetic. None of it will work, so just give intralipid and call to intraaortic pump peeps AKA cardiologists. Deposition CCU
    #4. Clonus with tachycardia makes me think serotonin syndrome. Usually SSRIs nawadays. But there is a specific statement that she is happy. Is it because she has been popping SSRIs without letting anyone know? This is not cholinergic since she is sweaty. Another possibilty is cocaine or any other sympathomimetic. That too potentially can make you happy for a while. Do the usual BW. If there is a question of intentional OD, get acetaminophen levels. Check beta because you always should. Treatment is supportive in any case.
    #5. NMS. Before you do anything, start cooling him. Send basic blood, but make sure to add CK, as they can get rhabdo. Fluids and benzodiazepines until rigidity resolved. Bromocriptine? Stop his meds.

  7. Just came across this.
    #3 sounds like clonidine toxicity- any formal feedback from original poster?

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