Toxidrome Recognition Chart

Signs and Symptoms of Common Poisoning Syndromes

⚠️ EMERGENCY REFERENCE - For suspected poisoning, contact Poison Control Center (1-800-222-1222) and/or emergency services immediately
Sympathomimetic: Stimulants, cocaine, amphetamines
Cholinergic: Organophosphates, nerve agents, pilocarpine
Anticholinergic: Atropine, scopolamine, antihistamines
Opioid: Morphine, heroin, fentanyl, prescription opioids
Neuroleptic: Antipsychotics, metoclopramide
Serotonin: SSRIs, MAOIs, tramadol, MDMA
Clinical Note: Toxidromes represent constellation of signs and symptoms. Mixed presentations are common with polydrug ingestions. Always consider co-ingestions and obtain comprehensive history.
Toxidrome Mental Status Eyes Lungs Vital Signs Bowel Sounds Bladder Neurological
Sympathomimetic GABAergic Withdrawal
Cocaine, amphetamines, caffeine, alcohol/benzo withdrawal
 Agitated Delirious Mydriasis
Dilated pupils
 Normal
May have tachypnea
 ↑ HR ↑ BP ↑ Temp ↑ RR Normal or Increased
Hyperactive
 Normal or Increased
Urinary retention possible
 Nonfocal Hyperreflexia
Tremor, seizures possible
Cholinergic
Organophosphates, carbamates, physostigmine, pilocarpine
 Normal
May progress to altered
 Miosis Mydriasis
Pinpoint then dilated
 Bronchorrhea
Excessive secretions, wheezing
 HR ↓ or ↑ BP ↓ or ↑ RR ↓ or ↑
Biphasic response
 Increased
Hyperactive, diarrhea
 Increased
Urinary incontinence
 Fasciculations Weakness
Muscle twitching
Anticholinergic
Atropine, scopolamine, antihistamines, tricyclics, jimsonweed
 Agitated Delirious
"Mad as a hatter"
 Mydriasis
"Blind as a bat"
 Normal
May be dry
 ↑ HR ↑ BP ↑ Temp
"Hot as a hare"
 Decreased
Absent bowel sounds
 Decreased
Urinary retention
 Nonfocal Ataxia
Poor coordination
Opioid Withdrawal
Morphine, heroin, fentanyl, oxycodone withdrawal
 Dysphoric
Anxious, irritable
 Mydriasis
Dilated pupils, lacrimation
 Normal
May have rhinorrhea
 ↑ HR (mild) Normal BP Normal Temp Increased
Hyperactive, cramping
 Increased
Frequent urination
 Nonfocal Ataxia
Tremor, restlessness
Neuroleptic Malignant Syndrome
Haloperidol, chlorpromazine, metoclopramide, risperidone
 Agitated Delirious
Altered consciousness
 Oculogyric Crises
(Rare finding)
 Normal
May have tachypnea
 ↑ HR ↑ BP ↑ Temp ↑ RR Normal
Usually unchanged
 Normal
Usually unchanged
 Lead-pipe Rigidity Cogwheel Rigidity
Extrapyramidal symptoms
Serotonin Syndrome
SSRIs, MAOIs, tramadol, MDMA, St. John's Wort
 Agitated Delirious
Confusion, euphoria
 Ocular Clonus
Nystagmus, dilated pupils
 Normal
May have tachypnea
 ↑ HR ↑ BP ↑ Temp ↑ RR Normal or Increased
May have diarrhea
 Normal or Increased
Usually unchanged
 Hyperreflexia Clonus
Lower extremity clonus most common

Abbreviations and Key Terms

BP: Blood Pressure
HR: Heart Rate
RR: Respiratory Rate
Temp: Temperature
GABA: Gamma-Aminobutyric Acid
SSRI: Selective Serotonin Reuptake Inhibitor
MAOI: Monoamine Oxidase Inhibitor
MDMA: 3,4-Methylenedioxymethamphetamine
Mydriasis: Dilated pupils
Miosis: Constricted pupils
Clonus: Rhythmic muscle contractions
Ataxia: Loss of coordination

Clinical Pearls

  • Anticholinergic mnemonic: "Mad as a hatter, red as a beet, hot as a hare, blind as a bat, dry as a bone"
  • Cholinergic mnemonic: SLUDGE (Salivation, Lacrimation, Urination, Diarrhea, GI upset, Emesis)
  • Mixed presentations: Always consider polydrug ingestions and drug interactions
  • Serotonin vs NMS: Serotonin syndrome has hyperreflexia and clonus; NMS has rigidity

Disclaimer: This chart is for educational and reference purposes only. It does not replace clinical judgment, comprehensive assessment, or toxicology consultation. PsychConcierge PLLC ("PsychConcierge.com") and its affiliates disclaim any liability arising from use or reliance on this content. For any suspected toxidrome or poisoning, immediate medical evaluation and consultation with a Poison Control Center is advised.