Appendix B. Health Effects of Chemical Exposure: Toxidromes

Human exposure to many chemicals can be hazardous and have mild to severe toxic effects. Syndromes caused by exposure to dangerous levels of toxins are referred to as toxidromes, a portmanteau of toxic and syndrome. Toxidromes are groups of signs and symptoms used to diagnose poisoning, typically grouped by clinical presentations and their countermeasures/treatments. Understanding toxidromes is valuable for identifying effective treatments and appropriate PPE based on clinical observations when specific chemical/source information is unavailable. A brief overview of nine common toxidromes, as defined by the Department of Homeland Security and National Library of Medicine5, are presented below.

Table 11: Chemical Toxidromes

Toxidrome
Category 		Clinical
Presentations 		Mechanism Causative
Chemicals 		Common
Antidotes
and
Treatment
Protocols
Solvents,
Anesthetics,
or
Sedatives (SAS)/
Organic Solvents
Toxidrome

Central nervous
system (CNS)
agitation
or depression
Behavioral changes

Slurred speech

Abnormal eye
movements
(nystagmus)

Ataxia
(difficulty walking/ balancing)

Chemical burns

Loss of
consciousness

Coma

Convulsions

Respiratory
arrest

Cardiac dysrhythmia
(irregular heartbeat)

Cardiac arrest

Catecholamine
release

GABA receptor
effects

Ion channel effects
in the brain

Gasoline

Benzene

Nitrous
oxide

Barbiturates

Methylene
chloride

Benzodiazepines

Artificial
ventilation

Flumazenil

Anticholinergic
Toxidrome

Blurred
vision

Confusion

Hallucinations

Coma

Pupil dilation
(mydriasis)

Increased body
temperature

Increased pulse

Decreased
sweating

Under-stimulation
of cholinergic
nerve receptors
leading to central nervous
system and respiratory
system depression

Atropine

Cogentin

BZ
(3-quinuclidinyl benzilate)

Hyoscyamine

Scopolamine

Physostigmine

Benzodiazepines

Anticoagulant
Toxidrome

Abnormal
bleeding

Lethargy

Pallor

Altered blood
coagulation

Superwarfarins

Coumadin

Fresh frozen
plasma

Whole blood
and
Factor VII
therapy

Vitamin K1

Cholinergic/Pesticide/Nerve
Agent Toxidrome

Pinpoint pupils
(miosis)

Seizures

Wheezes

Twitches

Excessive secretion
(sweat, tears, saliva, vomit, incontinence, etc.)

SLUDGE1

DUMBBELS2

Systemic gastrointestinal
and central nervous system
effects
progressing
to death
if untreated

Over-stimulation
of
cholinergic nerve receptors

Nerve agents
(e.g., GB/sarin, GA/tabun, GD/soman, and VX)

Organophosphorus
pesticides

Carbamate
pesticides

Fourth Generation Agents
(FGAs) (e.g., novichoks)

Atropine

2-PAM (oximes)

Benzodiazepines

Artificial ventilation

Scopolamine

Ketamine

Convulsant
Toxidrome

Convulsions,
can be fatal
when severe

Central nervous
system excitation;
glycine, GABA, or
glutamate antagonism

Strychnine

TETS3

Picrotoxin

Phenylsilatrane

Benzodiazepines

Barbiturates

Pyridoxine

Irritant/Corrosive
Toxidrome

Irritation of
exposed skin
and mucous
membranes

Coughs

Wheezes

Respiratory
distress

Gastrointestinal
effects

Blistering and
burns

Tearing/lacrimation

Irritating properties
produce
blisters on the skin
and/or damage
to the eyes, lung,
and other mucous membranes

Blister agents/vesicants

Mustard
agents

Lewisite

Choking/pulmonary
agents

Ammonia

Phosgene

Chlorine

Riot Control
Agents
(RCAs)

Ingestion: Anti-emetics,
activated charcoal

Inhalation: Oxygen,
bronchodilators, corticosteroids,
artificial ventilation,
sodium bicarbonate

Topical: Flushing,
oxygen,
pain medication

Knockdown/Asphyxiant/Blood Agent/Metabolic
Toxidrome

Confusion

Fatigue

Lightheadedness

Seizures

Coma

Loss of
consciousness

Cardiac arrest

Gastrointestinal
effects

Hair, nail,
kidney,
and neurological abnormalities

Disrupted oxygen delivery
to tissues Interference
with intracellular processes
leading to multiple
organ failure

Carbon monoxide

Cyanide

Aluminum
phosphide

Cyanogen chloride
(CK)

Arsenic

Mercury

Thallium

Cyanokit
(cyanide)

Sodium nitrite/sodium
thiosulfate kit
(cyanide)

Oxygen

Prussian Blue
(thallium)

Chelators, BAL or DMSA4
(arsenic)

Opioid
Toxidrome

Pinpoint pupils
(miosis)

Decreased pulse
and blood pressure

Decreased temperature

Decreased digestion

Respiratory failure

Opioid receptor
agonism leads to central nervous system
and
respiratory depression

Fentanyl

Carfentanil

Diacetylmorphine

Heroin

Oxycodone
(Oxycontin)

Hydrocodone
(Vicodin)

Naloxone

Artificial
ventilation

Stress-Response/Sympathomimetic/Stimulant
Toxidrome

Increased pulse,
respiration,
and
blood pressure

Confusion and panic

Increased pupil size

Hyperventilation

Sweating

Central nervous
system excitation

Caffeine

Nicotine

Amphetamines

Mephedrone

Benzodiazepines

Activated charcoal

Further details about the medical management of chemical exposures are available from:

Additional resources are listed in the Chemical Substance and Hazard Information Resources Appendix.

Footnotes

5. Report on the Toxic Chemical Syndrome Definitions and Nomenclature Workshop.

6. Salivation, Lacrimation (flow of tears), Urination, Defecation, Gastrointestinal Distress, and Emesis (vomiting)

7. Diarrhea, Urination, Muscles weakness/Miosis (pupil constriction), Bronchorrhea (excessive mucus, often resulting in phlegmy coughs), Bradycardia (slow heart rate), Emesis, Lacrimation, Salivation/Sweating

8. Tetramethylenedisulfotetramine

9. British Anti-Lewisite (BAL) and Dimocaptosuccinic Acid (DMSA), also called succimer

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