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Common Toxic Syndromes

Syndrome

Symptoms

Common Causes

Anticholinergic

Tachycardia, hyperthermia, mydriasis, warm and dry skin, urinary retention, ileus, delirium (a mnemonic in English for this combination of symptoms is “mad as a hatter, blind as a bat, red as a beet, hot as a hare, and dry as a bone”*)

Antihistamines

AtropineAtropine

Belladonna alkaloids

Datura (angel's trumpet)

Jimson weed

Mushrooms (some)

Psychoactive drugs (many)

ScopolamineScopolamine

Tricyclic antidepressants

Cholinergic, muscarinic

Salivation, Lacrimation, Urination, Defecation, GI cramps, Emesis (mnemonic in English: SLUDGE)

or

Diarrhea; Urination; Miosis; Bronchorrhea, Bradycardia, and Bronchoconstriction; Emesis; Lacrimation; and Salivation (mnemonic in English: DUMBELS)

Wheezing

Carbamates

Mushrooms (some)

Organophosphates†,

PhysostigminePhysostigmine

PilocarpinePilocarpine

PyridostigminePyridostigmine

Cholinergic, nicotinic

Mydriasis, Tachycardia, Weakness, Hypertension and Hyperglycemia, Fasciculations, Sweating (mnemonic in English is an acronym with the same letters as the days of the week: MTWT[h]FS)

Abdominal pain, paresis

Black widow spider bites

Carbamates

NicotineNicotine

Organophosphates (some)†,

Opioid§

Hypoventilation, hypotension, miosis, sedation, possibly hypothermia

Opioids (eg, buprenorphine, diphenoxylate, fentanyl, carfentanyl, norfentanyl, remifentanil, heroin, methadone, morphine, pentazocine, propoxyphene, oxycodone, hydromorphone)Opioids (eg, buprenorphine, diphenoxylate, fentanyl, carfentanyl, norfentanyl, remifentanil, heroin, methadone, morphine, pentazocine, propoxyphene, oxycodone, hydromorphone)

Sympathomimetic

Tachycardia, hypertension, mydriasis, agitation, seizures, diaphoresis, hyperthermia, psychosis (after chronic use)

Amphetamines

CaffeineCaffeine

CocaineCocaine

EphedrineEphedrine

Herbal and synthetic marijuana and common substitutes

MDMA (Ecstasy)

Phenylpropanolamine

Substituted cathinones ("bath salts")

"Synthetic" marijuana

TheophyllineTheophylline

Withdrawal (various drug classes)a

Tachycardia, mild hypertension, mydriasis, diaphoresis, agitation, restlessness, anxiety, hyperreflexia, piloerection, yawning, abdominal cramps, lacrimation, flu-like symptoms, insomnia, vomiting and diarrhea

Withdrawal from the following sedating or recreational drugs:

Agitation, hallucinations, confusion, disorientation, seizures, hyperreflexia, hypertension, tachycardia, arrhythmias, dehydration, autonomic instability, death, severe muscle spasm (baclofen)Agitation, hallucinations, confusion, disorientation, seizures, hyperreflexia, hypertension, tachycardia, arrhythmias, dehydration, autonomic instability, death, severe muscle spasm (baclofen)

Withdrawal from the following drugs with sedative-hypnotic effects:

Decreased mental alertness, lethargy, coma, decreased blood pressure, decreased heart rate

Withdrawal from the following drugs with sympathomimetic effects:

Mild flu-like symptoms, insomnia, restlessness and anxiety

Withdrawal from the following medications with antidepressant effects:

* From Carroll L: Alice's Adventures in Wonderland. London, MacMillan & Co., 1865.

Tuovinen K. Organophosphate-induced convulsions and prevention of neuropathological damages. Toxicology. 2004;196(1-2):31-39. doi:10.1016/j.tox.2003.10.013

Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet. 2008;371(9612):597-607. doi:10.1016/S0140-6736(07)61202-1

§Sharma B, Bruner A, Barnett G, Fishman M. Opioid Use Disorders. Child Adolesc Psychiatr Clin N Am. 2016;25(3):473-487. doi:10.1016/j.chc.2016.03.002

Brown H, Pollard KA. Drugs of Abuse: Sympathomimetics. Crit Care Clin. 2021;37(3):487-499. doi:10.1016/j.ccc.2021.03.002

aGortney JS, Raub JN, Patel P, et al. Alcohol withdrawal syndrome in medical patients. Cleve Clin J Med. 2016;83(1):67-79. doi:10.3949/ccjm.83a.14061

bFava GA, Cosci F. Understanding and Managing Withdrawal Syndromes After Discontinuation of Antidepressant Drugs. J Clin Psychiatry. 2019;80(6):19com12794. Published 2019 Nov 26. doi:10.4088/JCP.19com12794

GHB = gamma-hydroxybutyrate; MDMA = methylenedioxymethamphetamine; MAOI = monoamine oxidase inhibitor; PCP = phencyclidine; SSRI = selective serotonin reuptake inhibitor.