Sedative Toxidrome
AGENTS
- opioids
- benzodiazepines
- barbiturates
- baclofen (may mimic brain death, suspect in MS patients)
- clonidine (mimics opioid toxidrome with marked bradycardia and hypotension)
- GHB
CLINICAL FEATURES
- sedation
- coma
- pupillary changes
- respiratory and cardiovascular depression
INVESTIGATIONS
- urine drug screen – not useful acutely, many drawbacks
SPECIFIC MANAGEMENT AND TRIGGERS FOR INTERVENTION
Opioids
- naloxone: titrated doses until reversal of respiratory depression -> may require an infusion
- dose: 0.04-2mg IV/IM/SC/ INH/IN -> 1-10mcg/kg/hr
- best to give in small increments while providing respiratory support
Barbiturates
- supportive care
- multiple doses of activated charcoal
- alkaline diuresis
- haemoperfusion
Benzodiazepines
- supportive care
- avoid flumazenil if possible – may precipitate withdrawal or intractable seizures
- consider flumazenil in pediatric ingestion or if benzodiazepines were administered for procedural sedation
- flumazenil: titrated doses until reversal of respiratory depression -> may require an infusion
- dose: 0.2mg IV -> 0.1-0.4mg/hr
Clonidine
- supportive care
- trial naloxone
GHB
- supportive care
- coma should resolve <6 hours, unless diagnosis wrong or re-ingestion!
Baclofen
- supportive care
- like barbiturates, may mimic brain death
References and Links
CCC Toxicology Series
General
Approach to acute poisoning, ECGs in Tox, Evidenced-based Tox, Toxicology literature summaries, Does anti-venom work?
Toxins / Overdose
Amphetamines, Barbituates, Benzylpiperazine, Beta Blockers, Calcium Channel Blocker, Carbamazepine, Carbon Monoxide, Ciguatera, Citrate, Clenbuterol, Cocaine, Corrosive ingestion, Cyanide, Digoxin, Ethanol, Ethylene Glycol, Iron, Isoniazid, Lithium, Local anaesthetic, Methanol, Monoamine oxidase inhibitor (MAOI), Mushrooms (non-hallucinogenic), Opioids, Organophosphate, Paracetamol, Paraquat, Plants, Polonium, Salicylate, Scombroid, Sodium channel blockers, Sodium valproate, Theophylline, Toxic alcohols, Tricyclic antidepressants (TCA)
Envenomation
Marine, Snakebite, Spider, Tick paralysis
Syndromes
Alcohol withdrawal, Anticholinergic syndrome, Cholinergic syndrome, Drug withdrawals in ICU, Hyperthermia associated toxidromes, Malignant hyperthermia (MH), Neuroleptic malignant syndrome (NMS), Opioid withdrawal, Propofol Infusion Syndrome (PrIS) Sedative toxidrome, Serotonin syndrome, Sympatholytic toxidrome, Sympathomimetic toxidrome
Decontamination
Activated Charcoal, Gastric lavage, GI Decontamination
Enhanced Elimination
Enhanced elimination, Hyperbaric therapy for CO
Antidotes
Antidote summary, Digibind, Glucagon, Flumazenil, HIET – High dose euglycaemic therapy, Intralipid, Methylene Blue, N-Acetylcysteine (NAC), Naloxone
Miscellaneous
Cocaine chest pain, Digoxin and stone heart theory, Hyperbaric oxygen, Hypoxaemia in tox, Liver failure in tox, Liver transplant for paracetamol, Methaemoglobinaemia, Urine drug screen
- Tox Conundrum – Alprazoslammed
- Tox Conundrum – Brain Dead?
- Tox Conundrum – Two Pills can Kill
- Tox Conundrum – A Toxic Slumber
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC