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TABLE 102.8
IMPORTANT DRUGS AND TOXICANTS NOT DETECTED BY MOST
DRUG SCREENS
Antidysrhythmics
β-Blockers
Anticoagulants
Calcium channel blockers
Anticonvulsants
Hypoglycemics
Antidepressants (TCAs, SSRIs)
Colchicine
Antipsychotics
Solvents
Clonidine
Toxic alcohols
Cyanide
Synthetic opioids (i.e., methadone,
buprenorphine, fentanyl, etc.)
Designer drugs:
MDMA, γ-hydroxybutyrate, ketamine Plant and mushroom toxins
Organophosphates
Tetrahydrozoline (in over-the-counter eyedrops)
Adapted from Goldfrank LR, Flomenbaum NE, Lewin NA, et al., eds. Goldfrank’s Toxicologic Emergencies .
9th ed. New York: McGraw-Hill; 2009.

Assessment of Severity and Diagnosis
At this juncture, most intoxicated patients may be stratified by specific toxicant or
category of drug(s) ingested and some judgment made as to the potential or
current severity of the exposure. For some children, clinical features of a complex
illness of acute onset may suggest intoxication without a specific history of such
ingestion. In a few cases, some laboratory confirmation of clinical suspicion will

be available on an immediate basis. Using all the clinical clues available and with
some familiarity of the toxidrome approach to differential diagnosis as detailed
previously ( Tables 102.5 and 102.6 ) and, at times, with help from the laboratory,
the emergency physician must now establish a working diagnosis and proceed
with consideration of options for specific detoxification.
Specific Detoxification
Again, the patient must be continually reassessed and managed for impaired vital
function. All decisions about further decontamination and/or specific antidotal
therapy involve a complex interplay between the toxicant(s) ingested and the
patient’s condition.