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tox.sympathomimetic-toxidrome.core.v1

Sympathomimetic toxidrome

toxicologyacuteadultpediatricacuteinpatient
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manifest pointer is a PLACEHOLDER reusing prisma/seed/manifests/tox.salicylate-overdose.core.v1.ts — a dedicated tox.sympathomimetic-toxidrome manifest is NOT yet authored (tracked in design-brief Open gaps). No problem-package folder / atom manifests on disk; design brief authored alongside this dossier. Regimen drugs intentionally carry NO rxcui — RxNav validation deferred (Stage-A API checklist in brief); non_pharm:true set for cooling, paralysis/intubation, whole-bowel irrigation, RRT, free-water restriction. workup ids (workup.hyperthermic_toxidromes / workup.cocaine_chest_pain / workup.severe_agitation), calculators (calc.qsofa, calc.news2), and panels (panel.metabolic/tox_screen/cardiac/renal/cbc/abg) drawn from the authorized whitelist; cascade.electrolyte used for hyponatremia. Unopposed-alpha caution for cocaine encoded as a contraindication_rule with explicit note that the labetalol / combined alpha-beta-blocker evidence is evolving and debated (AHA 2024). Bayesian likelihood-ratio enrichment for toxidrome discriminators (skin moisture, clonus, bowel sounds) deferred — see brief Open gaps. Deepened 2026-05-16: 6-step benzodiazepine-anchored regimen ladder (sedation → cooling → fluids/rhabdo-AKI → cocaine cardiac/HTN → bicarbonate wide-QRS → severe hyponatremia), ED + ICU playbooks, 6 severity triggers, siblings vs anticholinergic toxidrome and serotonin syndrome.

Entry points (5)

  • symptom
    Reported / suspected cocaine, amphetamine, methamphetamine, MDMA, "bath salts", or prescription stimulant use [ACMT agitation guidance]
    stimulant_use_history
  • symptom
    Severe agitation / psychosis + tachycardia + hypertension + DIAPHORESIS + mydriasis (sympathomimetic toxidrome cluster) [Goldfrank tox]
    agitated_hyperadrenergic_state
  • vital_abnormality
    Core temperature >38.5°C with agitation/combativeness (excited-delirium / hyperthermic toxidrome) [AHA 2024 cocaine statement]
    hyperthermia_with_agitation
  • symptom
    Chest pain after cocaine/stimulant use (coronary vasospasm / ACS) [AHA 2024 cocaine cardiovascular statement]
    cocaine_associated_chest_pain
  • lab_abnormality
    Urine drug screen positive for cocaine/amphetamine metabolites (confirmatory, not gating) [ACMT]
    positive_stimulant_uds

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Pediatric unintentional ingestion / "body-stuffer" teen; weight-based benzodiazepine and fluid dosing [ACMT]
  • weight_kgrequired
    demographic • used at CONTEXT
    Weight-based benzodiazepine, fluid, and bicarbonate dosing [ACMT agitation guidance]
  • agent_classrequired
    history • used at CONTEXT
    Cocaine (Na-channel + vasospasm + unopposed-alpha caution) vs MDMA (hyponatremia + serotonin overlap) vs cathinones (prolonged severe agitation) drives branch-specific therapy [AHA 2024; ACMT]
  • route_and_body_packingrequired
    history • used at CONTEXT
    Body-packer vs body-stuffer changes decontamination (whole-bowel irrigation, NO endoscopic cocaine-packet removal, surgery if rupture/obstruction) [ACMT]
  • co_ingestants_serotonergicsrequired
    history • used at CONTEXT
    MDMA + SSRI/MAOI/linezolid → serotonin-syndrome overlap; ethanol/opioid co-use alters sedation plan [ACMT]
  • core_temperaturerequired
    vital • used at RED_FLAGS
    Hyperthermia is the leading mortality driver — drives aggressive active cooling and paralysis/intubation if refractory [AHA 2024]
  • hrrequired
    vital • used at RED_FLAGS
    Sinus tachycardia / arrhythmia severity; benzodiazepine titration target [ACMT]
  • sbprequired
    vital • used at RED_FLAGS
    Severe HTN / hypertensive emergency drives phentolamine/nitrate/CCB; hypotension/collapse signals excited delirium [AHA 2024]
  • mental_status_agitationrequired
    symptom • used at RED_FLAGS
    Agitation/psychosis severity drives benzodiazepine dosing; obtundation/collapse = excited-delirium decompensation [ACMT]
  • skin_moisturerequired
    symptom • used at RED_FLAGS
    DIAPHORESIS (wet skin) is the cardinal pivot vs anticholinergic anhidrotic dry/flushed skin [Goldfrank tox]
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Cocaine Na-channel blockade → wide QRS (bicarbonate); QT prolongation; ischemia from vasospasm [AHA 2024]
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    MDMA water intoxication / SIADH → severe hyponatremia with seizures; guides hypertonic-saline decision [ACMT]
  • creatine_kinaserequired
    lab • used at INITIAL_WORKUP
    Agitation + hyperthermia → rhabdomyolysis; CK trend drives aggressive fluids [ACMT]
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Rhabdomyolysis-associated AKI; baseline renal function for fluid/contrast decisions [ACMT]
  • troponin
    lab • used at INITIAL_WORKUP
    Cocaine-associated chest pain / myocardial injury workup [AHA 2024]
  • venous_or_arterial_phrequired
    lab • used at INITIAL_WORKUP
    Metabolic (lactic) acidosis tracks excited-delirium severity and impending cardiovascular collapse [AHA 2024]
  • glucoserequired
    lab • used at INITIAL_WORKUP
    Hypoglycemia is a universal AMS mimic; co-screen mandatory [ACMT]
  • pregnancy_status
    history • used at CONTEXT
    Cocaine placental abruption risk; alters imaging and obstetric escalation [AHA 2024]

12-phase flow (12)

  1. 1FRAME
    Recognize the sympathomimetic toxidrome and triage the hyperthermic/excited-delirium subset (the highest-mortality phenotype) up front [AHA 2024 cocaine cardiovascular statement]
    inputs: core_temperature, mental_status_agitation
    advance: Toxidrome recognized; hyperthermic/excited-delirium subset flagged
  2. 2ENTRY
    Capture trigger — stimulant-use history, hyperadrenergic agitation cluster, cocaine chest pain, or hyperthermia with combativeness [ACMT agitation guidance]
    inputs: age
    advance: Trigger captured
  3. 3CONTEXT
    Capture agent class (cocaine vs amphetamine/meth vs MDMA vs cathinones vs Rx stimulant), route, body-packer/stuffer status, serotonergic co-ingestants, ethanol/opioid co-use, pregnancy [AHA 2024; ACMT]
    inputs: weight_kg, agent_class, route_and_body_packing, co_ingestants_serotonergics, pregnancy_status
    advance: Agent class + route + co-ingestant context classified
  4. 4RED_FLAGS
    Hyperthermia >40°C, excited delirium with metabolic acidosis / impending cardiovascular collapse, wide-QRS from cocaine, status epilepticus, severe hyponatremia seizure, cocaine ACS, hypertensive emergency / aortic dissection / ICH [AHA 2024]
    inputs: core_temperature, hr, sbp, mental_status_agitation, skin_moisture
    actions: workup.hyperthermic_toxidromes, calc.news2
    advance: Red flags screened; ICU/resuscitation triggered for any positive
  5. 5INITIAL_WORKUP
    Core temp, ECG (QRS/QTc/ischemia), CMP + Na + Cr + glucose, CK, lactate/VBG, troponin (if chest pain), CBC, UDS (confirmatory), acetaminophen + salicylate + ethanol co-screen, β-hCG; CT head/CTA for focal deficit or tearing pain [AHA 2024; ACMT]
    inputs: ecg_12_lead, sodium, creatine_kinase, creatinine, venous_or_arterial_ph, glucose
    actions: panel.metabolic, panel.tox_screen, panel.cardiac, panel.renal, panel.cbc
    advance: Toxidrome confirmed and end-organ panel resulted
  6. 6BRANCHING_WORKUP
    Branch by syndrome: cocaine chest pain → ACS pathway (ECG/troponin/serial); wide-complex tach → Na-channel-blockade pathway; psychosis/severe agitation → excited-delirium pathway; first seizure → neuro/hyponatremia workup; tearing chest/back pain → CTA aortic dissection; body-packer → abdominal imaging [AHA 2024; ACMT]
    inputs: ecg_12_lead, troponin, sodium
    actions: workup.cocaine_chest_pain, workup.wide_complex_tach, workup.acute_psychosis, workup.severe_agitation, workup.first_seizure, workup.delirium
    advance: Syndrome branch(es) selected
  7. 7DIFFERENTIAL
    Distinguish from anticholinergic toxidrome (DIAPHORETIC vs anhidrotic dry skin; bowel sounds present vs ileus), serotonin syndrome (clonus/hyperreflexia + serotonergic-drug history), NMS, thyroid storm, sepsis, alcohol/sedative withdrawal, salicylate toxicity, hypoglycemia, primary psychiatric agitation [Goldfrank tox; ACMT]
    inputs: skin_moisture, co_ingestants_serotonergics
    advance: Sympathomimetic toxidrome confirmed as principal driver
  8. 8RISK_STRATIFICATION
    Stratify by hyperthermia tier, acidosis depth, QRS width, end-organ injury (rhabdo/AKI/ACS/ICH/dissection), hyponatremia severity, and agitation/sedation-failure; qSOFA/NEWS2 for collapse risk and ICU disposition [AHA 2024]
    inputs: core_temperature, venous_or_arterial_ph, creatine_kinase
    actions: calc.qsofa, calc.news2
    advance: Severity tier assigned; ICU disposition decided
  9. 9TREATMENT
    Liberal titrated BENZODIAZEPINES first-line (agitation/tachycardia/HTN/seizure); aggressive ACTIVE COOLING to rapid normothermia (paralysis + intubation if refractory hyperthermia); IV fluids + rhabdo/AKI management; cocaine cardiac/HTN — nitroglycerin + phentolamine + CCB + aspirin (AVOID nonselective beta-blockers acutely — unopposed-alpha caution); sodium bicarbonate for cocaine wide-QRS; cautious management of severe hyponatremia (hypertonic saline if seizing); antipsychotics avoided/adjunct-only; whole-bowel irrigation for confirmed body-packers [AHA 2024; ACMT agitation guidance]
    inputs: core_temperature, mental_status_agitation, sbp, ecg_12_lead, sodium
    advance: Benzodiazepine sedation + active cooling + fluids in flight; syndrome-specific therapy started
  10. 10DISPOSITION
    ICU for hyperthermia, excited delirium, refractory agitation, wide-QRS, cocaine ACS, severe hyponatremia, or end-organ injury; toxicology + poison-center consult; psychiatry/SUD referral once medically stable; surgery for packer rupture/obstruction [ACMT]
    advance: Disposition + consults assigned
  11. 11MONITORING
    Continuous telemetry + core-temp monitoring, q15–30min vitals during cooling/sedation, serial ECG until QRS/QTc normalize, q4–6h CK + renal until trending down, serial Na if MDMA hyponatremia, lactate clearance, UOP, capnography if intubated [AHA 2024]
    inputs: core_temperature, hr, creatine_kinase, sodium
    actions: panel.metabolic, panel.renal, panel.cardiac
    advance: Normothermic, agitation controlled, no end-organ deterioration, levels/labs trending to baseline
  12. 12FOLLOWUP
    Substance-use disorder referral + harm reduction (naloxone co-prescription if opioid co-use), cardiology follow-up for cocaine-associated myocardial injury, nephrology if AKI, psychiatry safety plan if intentional, social work [AHA 2024; ACMT]
    advance: Disposition plan + SUD/psych follow-up documented