Overdose & Toxidrome Thinking

Why This Is Hard

Polysubstance use is common. Bottles lie. Patients cannot history. Toxidrome thinking gives you a pattern language so you protect the airway and choose the right antidote pathway without inventing hospital toxicology in the truck.

High-Yield Patterns (Education)

• Opioid: miosis (variable with polysubstance), hypoventilation, AMS — naloxone to restore breathing, not necessarily full wakefulness.
• Sympathomimetic (cocaine/meth): agitation, tachycardia, hypertension, hyperthermia, diaphoresis — cool, calm, benzos per protocol; watch for trauma and ACS.
• Anticholinergic: mad as a hatter, hot/dry, dilated pupils, urinary retention themes — supportive care; specific antidotes only if protocol allows.
• Cholinergic (organophosphate): SLUDGE/DUMBELS education lists — scene safety critical; atropine/pralidoxime only per hazmat/protocol systems.
• Sedative-hypnotic: AMS with relatively preserved vitals early — supportive airway.

EMS Priorities

1. Scene safety (fentanyl powder myths vs real PPE policy — follow your service rules).
2. Airway/ventilation first for hypoventilating patients.
3. Glucose in AMS.
4. 12-lead when chest pain/sympathomimetic stress.
5. Antidotes only as authorized; bring bottles/packets to ED.
6. Do not induce vomiting; decontamination is limited in the field.

Key Points for Paramedics

• Treat the patient, not the drug name alone.
• Hypoventilation kills more opioid patients than “low SpO₂ alone” thinking.
• Excited delirium / severe agitation pathways — follow restraint and sedation protocols carefully.

Field Pitfalls

• Large naloxone doses causing violent withdrawal when smaller titrations are allowed.
• Missing trauma under intoxication.
• Entering a unsafe chemical scene without training.

Practice

Name the toxidrome for three vignettes your partner invents. Related: Naloxone, AMS.

Sources & Further Study

• Poison control education partnerships; your OD and hazmat protocols.