Chart — Emergency Nursing · Pharmacology
Toxidrome Comparison Chart
Five major toxidromes compared side-by-side — vital signs, pupils, mental status, skin, bowel, antidotes, and nursing priorities to rapidly identify and treat poisoning patterns.
Educational use only. Toxidrome patterns support assessment and recognition only; poisoning management is directed by providers and regional poison control. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Key assessment axes: Vital signs (HR, BP, RR, Temp) + Pupils + Mental status + Skin (wet vs dry) + GI/secretions = differentiates most toxidromes within seconds.
| Feature | Opioid | Anticholinergic | Cholinergic | Sympathomimetic | Sedative-Hypnotic |
|---|---|---|---|---|---|
| Causative Agents | Heroin, morphine, oxycodone, hydrocodone, fentanyl, methadone, tramadol | Antihistamines (diphenhydramine), TCAs, atropine, scopolamine, antipsychotics, jimsonweed, some mushrooms | Organophosphate pesticides (parathion, malathion), nerve agents (sarin, VX), carbamates, some mushrooms | Cocaine, amphetamines, methamphetamine, MDMA, ephedrine, pseudoephedrine | Benzodiazepines, barbiturates, alcohol (ethanol), GHB, zolpidem |
| Heart Rate | Bradycardia | Tachycardia ↑↑ | Bradycardia ↓↓ | Tachycardia ↑↑ | Bradycardia (mild) |
| Blood Pressure | Hypotension | Hypertension | Hypotension | Hypertension ↑↑ | Hypotension |
| Respiratory Rate | Bradypnea → apnea (life-threatening) | Tachypnea (mild) | Bronchospasm → respiratory failure | Tachypnea | Bradypnea (variable) |
| Temperature | Hypothermia | Hyperthermia ↑↑ ('hot as Hades') | Normal or mildly low | Hyperthermia ↑↑ | Hypothermia |
| Pupils | MIOSIS (pinpoint) — hallmark | MYDRIASIS (dilated) — 'blind as a bat' | MIOSIS (constricted) — hallmark | MYDRIASIS (dilated) | Variable / mid-position (may be small) |
| Mental Status | CNS depression, sedation → coma | Agitation, delirium, visual hallucinations ('mad as a hatter') | Anxiety → confusion → seizures → coma | Agitation, paranoia, psychosis, hallucinations | Sedation, slurred speech, ataxia → coma |
| Skin | Pale, cool, clammy | HOT, DRY, FLUSHED ('dry as a bone, red as a beet') | Diaphoresis (WET) — hallmark | Diaphoresis (wet — differentiates from anticholinergic) | Cool, pale (variable) |
| Bowel / GI | Decreased bowel sounds; constipation | Absent or decreased bowel sounds; urinary retention ('full as a flask') | SLUDGE — increased secretions, diarrhea, cramping, urination, vomiting (wet bowel sounds) | Nausea, decreased GI motility | Decreased bowel sounds |
| Other Findings | Track marks (IV use); reduced deep tendon reflexes; pulmonary edema (fentanyl/heroin) | Urinary retention; absent sweat glands; flushed dry mucosa; tachycardia most prominent feature in mild cases | SLUDGE + DUMBELS mnemonic; bronchospasm; hypersalivation; lacrimation; ORGANOPHOSPHATES = hazmat decontamination required | Rhabdomyolysis from hyperthermia/seizures; cocaine: coronary vasospasm/MI; MDMA: hyponatremia | Nystagmus (alcoholic gaze nystagmus); ataxia; slurred speech; alcohol: hypoglycemia |
| Antidote | NALOXONE (Narcan) 0.4–2 mg IV/IM/IN; repeat q2-3 min; infusion for long-acting opioids | PHYSOSTIGMINE (specific — NOT for TCA); benzos for agitation; do NOT use physostigmine for TCA toxicity (seizures/asystole risk) | ATROPINE (large doses — titrate to DRY secretions, not HR) + PRALIDOXIME (2-PAM) early | No specific antidote. BENZODIAZEPINES for agitation, HTN, seizures. Avoid beta-blockers in cocaine (unopposed alpha). | FLUMAZENIL for benzodiazepines ONLY (caution: seizures in dependent patients). Otherwise supportive. |
| Priority Nursing Action | Airway + respiratory support first. BVM if apneic. Naloxone (titrate to respirations, NOT full reversal — avoid withdrawal). Observe for re-sedation. | Cool measures for hyperthermia. Benzos for agitation/seizures. Cardiac monitoring (TCA: QRS widening). Foley for urinary retention. | DECONTAMINATE FIRST (PPE, remove clothing, water irrigation). Atropine titration. 2-PAM early. Respiratory suction and support. | Benzos first-line for agitation/hypertension/seizures. Cooling for hyperthermia. 12-lead ECG (cocaine MI). Check CK for rhabdomyolysis. | Airway protection and aspiration precautions. Check blood glucose (alcohol). Monitor for re-sedation. Flumazenil caution. |
| NCLEX Memory Aid | 'Pinpoint pupils + bradypnea + coma = opioid → Narcan' | 'Hot, blind, dry, red, mad, full, fast' (Hades, bat, bone, beet, hatter, flask, fiddle) | 'SLUDGE = all secretions wet' — atropine dries it all. 2-PAM reactivates cholinesterase. | 'Wet + hyper everything + dilated' — benzos first. Avoid beta-blockers with cocaine. | 'Sedation, slurred, ataxia' — flumazenil reverses benzos ONLY. Not alcohol. |
Pupils Summary
MIOSIS (pinpoint): Opioids, Cholinergics (organophosphates)
MYDRIASIS (dilated): Anticholinergics, Sympathomimetics
Variable/mid-position: Sedative-hypnotics (less diagnostic)
Skin Summary (Dry vs Wet)
DRY (anhydrotic): Anticholinergic — hot, dry, flushed
WET (diaphoretic): Cholinergic — all secretions increased
WET (diaphoretic): Sympathomimetic — but HOT (differentiates from cholinergic)
Anticholinergic vs Sympathomimetic: both dilated pupils + tachycardia. Key difference: anticholinergic = DRY; sympathomimetic = WET (diaphoretic)
Antidote Quick Reference
Opioid: Naloxone (Narcan) — titrate to respirations, not consciousness
Anticholinergic: Physostigmine (NOT for TCA) / Benzos for agitation
Cholinergic/Organophosphate: Atropine (dry secretions) + Pralidoxime 2-PAM (early — before aging)
Sympathomimetic: Benzodiazepines (NO beta-blockers for cocaine)
Sedative-Hypnotic: Flumazenil for benzodiazepines ONLY (contraindicated in benzo-dependent patients)
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with Emergency Nurses Association (ENA) · AHA ACLS / PALS Guidelines · Advanced Trauma Life Support (ATLS). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →