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Sympathomimetic toxicity
From WikEM
Contents
Types
Sympathomimetics
Differential Diagnosis
Altered mental status and fever
- Infectious
- Sepsis
- Meningitis
- Encephalitis
- Cerebral malaria
- Other
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Malignant hyperthermia
- Sympathomimetic toxicity (cocaine, amphetamine, ketamine)
- Anticholinergic toxicity
- Heat stroke
- Delirium tremens
- Hypothalamic stroke
- Pheochromocytoma
- Thyroid storm
Toxidrome Chart
| Finding | Cholinergic | Anticholinergic | Sympathomimetic | Sympatholytic^ | Sedative/Hypnotic |
| Example | Organophosphates | TCAs | Cocaine | Clonidine | ETOH |
| Temp | Nl | Nl / ↑ | Nl / ↑ | Nl / ↓ | Nl / ↓ |
| RR | Variable | Nl / ↓ | Variable | Nl / ↓ | Nl / ↓ |
| HR | Variable | ↑ | ↑ (sig) | Nl / ↓ | Nl / ↓ |
| BP | ↑ | ↑ | ↑ | Nl / ↓ | Nl / ↓ |
| LOC | Nl / Lethargic | Nl, agitated, psychotic, comatose | Nl, agitated, psychotic | Nl, Lethargic, or Comatose | Nl, Lethargic, or Comatose |
| Pupils | Varriable | Mydriatic | Mydriatic | Nl / Miotic | |
| Motor | Fasciculations, Flacid Paralysis | Nl | Nl / Agitated | Nl | |
| Skin | Sweating (sig) | Hot, dry | Sweating | Dry | |
| Lungs | Bronchospasm / rhinorrhea | Nl | Nl | Nl | |
| Bowel Sounds | Hyperactive (SLUDGE) | ↓ / Absent | Nl / ↓ | Nl / ↓ |
- ^Consider Sympatholytic when looking at Sedative OD or someone who doesn't respond to Narcan
- Withdrawal from substances have the opposite effect
Evaluation
Work Up
Laboratory
- Finger stick glucose (to rule out hypoglycemia)
- Acetaminophen and Salicylate level
- Urine Drug Screen (to verify toxic substance, do not delay treatment for results)
- Serum electrolytes
- Serum creatine phosphokinase
- Creatinine and BUN
- Urine analysis with myoglobin
- Arterial or venous blood gas if respiratory symptoms present
Cardiac
- ECG for prolongation of QTc or QRS intervals
Management
- Use Benzodiazepines as first line agent for agitation, hypertension, and hyperthermia
- May also use Nitroprusside or Phentolamine
- Treat with fluid resuscitation to avoid renal failure secondary to rhabdomyolysis (see below)
Avoid
- Avoid succinylcholine due to potential for hyperkalemia in these patients
- Avoid antipyretics
- Avoid pure beta-blockers
Disposition
Complications
- Rhabdomyolysis is common complication [1]
- Bath Salts - 63% [1]
- Amphetamines - 40%
- Cocaine - 33%
