252 Emergency Medicine
acetaminophen poisoning. This phase usually lasts 0.5 to 24 hours. Patients
are usually asymptomatic or exhibit findings such as nausea, vomiting,
anorexia, malaise, and diaphoresis.
221.The answer is b.(Rosen, pp 2064-2066.)The term toxidromerefers
toa constellation of physical findingsthat can provide important clues in
a toxic ingestion. This is particularly useful in patients that cannot provide
an adequate history. The anticholinergic syndrometypically presents with
delirium, mumbling speech, tachycardia, elevated temperature, flushed face,
dry mucous membranes and skin, dilated pupils, and hypoactive bowel
sounds. The anticholinergic syndrome can be remembered by the phrase
“blind as a bat (mydriasis), red as a beet (flushed skin), hot as a hare (hyper-
thermia secondary to lack of sweating), dry as a bone (dry mucous mem-
branes), and mad as a hatter (mental status changes).”
(a)The sympathomimetic syndrome is usually seen after ingestion of
cocaine, amphetamines, or decongestants. It typically presents with delirium,
paranoia, tachycardia, hypertension, hyperpyrexia, diaphoresis, mydriasis,
seizures, and hyperactive bowel sounds. Sympathomimetic and anticholinergic
syndromes are frequently difficult to distinguish. The main difference is that
sympathomimetics usually cause diaphoresis whereas anticholinergics cause
dry skin. (c)The cholinergic syndrome is commonly remembered by the
mnemonics SLUDGE or DUMBBELS. (d and e)Opioids and ethanol are part
of the sedative-hypnotic syndrome. It typically presents with sedation, miosis,
respiratory depression, hypotension, bradycardia, hypothermia, and decreased
bowel sounds.
222.The answer is c.(Goldfrank et al, pp 480-496.)The patient presents
to the ED with central nervous system (CNS) and respiratory depression
and miotic pupils. Along with his history of heroin abuse and fresh needle
marks, this is most likely a heroin overdose.Opioid toxicity is associated
with the toxidrome of CNS depression, respiratory depression, and miosis.
Attention is always first directed at airway managementin emergency
medicine. The first action for this patient is to provide oxygen via bag-
valve-mask ventilation. Because his respiratory depression is most likely
secondary to opioid overdose, an opioid antagonistshould be adminis-
tered. Naloxoneis the antidote most frequently used to reverse opioid tox-
icity. The goal of naloxone therapy is not necessarily complete arousal;
rather, it is to reinstitute adequate spontaneous respiration, while attempt-
ing to avoid inducing acute opioid withdrawal.