Toxidrome Reference Chart

⚠️ EMERGENCY REFERENCE - For suspected poisoning, contact Poison Control Center (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

Sedative-Hypnotic: Benzodiazepines, barbiturates, GHB, ethanol

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	Antidote
Sympathomimetic GABAergic Withdrawal Cocaine, amphetamines, caffeine, alcohol/benzo withdrawal	Agitated Delirious	Mydriasis Dilated pupils	Normal May have tachypnea	↑ HR ↑ BP ↑ Temp ↑ RR Diaphoresis	Normal or Increased Hyperactive	Normal or Increased Urinary retention possible	Nonfocal Hyperreflexia Tremor, seizures possible	Benzodiazepines Titrate to sedation; avoid beta-blockers in cocaine
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	Atropine + Pralidoxime Atropine: double q5min until bronchorrhea resolves
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	Physostigmine 0.5–2 mg IV; contraindicated if QRS >100ms or seizures
Opioid Intoxication Morphine, heroin, fentanyl, oxycodone, methadone	Drowsy → Stupor → Coma "On the nod"	Miosis Pinpoint pupils; mydriasis if hypoxic	Respiratory Depression Hypoventilation, apnea; pulmonary edema possible	↓ HR ↓ BP ↓ RR ↓ Temp	Decreased Hypomotility	Urinary Retention	Hyporeflexia Flaccidity	Naloxone 0.04–2 mg IV/IM/IN; titrate to respiratory effort, not full arousal
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	Supportive Care Clonidine, loperamide for symptom relief
Sedative-Hypnotic Benzodiazepines, barbiturates, GHB, ethanol, zolpidem	Drowsy → Stupor → Coma Anterograde amnesia common	Normal or Miosis Mid-position or small; NOT pinpoint	Respiratory Depression Less severe than opioids unless mixed overdose	↓ HR ↓ BP ↓ RR ↓ Temp	Decreased	Normal or Urinary Retention	Slurred Speech Ataxia Nystagmus Hyporeflexia	Supportive Care ± Flumazenil Flumazenil contraindicated if chronic benzo use, seizure hx, TCA coingestion
Neuroleptic Malignant Syndrome Haloperidol, chlorpromazine, metoclopramide, risperidone, prochlorperazine	Agitated → Delirious → Coma Altered consciousness; may be mute	Normal or Oculogyric Crises (Rare finding)	Normal May have tachypnea	↑ HR ↑ BP ↑↑ Temp ↑ RR Often >40°C/104°F	Normal Usually unchanged	Normal Usually unchanged	Lead-pipe Rigidity Bradyreflexia Tremor Dysphagia Extrapyramidal symptoms	Dantrolene ± Bromocriptine Dantrolene 1–2.5 mg/kg IV; stop offending agent; aggressive cooling
Serotonin Syndrome SSRIs, MAOIs, tramadol, MDMA, St. John's Wort, linezolid	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 Myoclonus Lower extremity clonus most common	Cyproheptadine + Benzodiazepines Cyproheptadine 12 mg PO initially, then 2 mg q2h

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

GHB: Gamma-Hydroxybutyrate

TCA: Tricyclic Antidepressant

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)
Opioid intoxication triad: "Coma, Constricted pupils, Respiratory depression"
Sedative-hypnotic vs. opioid differentiation: Pupils are the key – pinpoint pupils suggest opioids; normal/mid-position pupils with ataxia, slurred speech, and nystagmus suggest sedative-hypnotics
Serotonin vs NMS: "Rigid and slow = NMS; Clonus and hyperreflexia = Serotonin Syndrome." NMS develops over days with lead-pipe rigidity and decreased reflexes; serotonin syndrome develops within hours with hyperreflexia and clonus
Naloxone titration: Goal is to restore respiratory drive, not full consciousness – over-reversal precipitates withdrawal
Flumazenil caution: Avoid in undifferentiated coma, chronic benzodiazepine users, seizure history, or suspected TCA coingestion
Mixed presentations: Always consider polydrug ingestions and drug interactions

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.