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

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