I was thinking before I came up here, I took the initial exam back in 89. And then the research was sent to you. You could do it on your own. Seven years later, I got another research. The scariest day of my life was five years later when I had to go to Prometrics. And I'll come back to Prometrics later. But taking the exam, the girl next to me was doing her SAT, like, I'm writing. And the guy next to me was there for a civil service job. And he's like, well, hey, I'm like, oh, my god. So that was quite an experience. Then I was a guinea pig for MOC, so I've been doing this a long time. So I hate to stand up here and guess what's going to be on the test, but there are certain things that just never go away. All right, so here we go. So AEIOUthips, we talked about altered mental status. Toxidromes, so just memorize this. I'll be back in 20 minutes. So we're going to go through this. I made this one up. And if you look at the end of all my slide sets, both the TED Talk one that we're doing today and the official long one, there are different. Everybody likes different styles. I sort of made this one up myself. And it was a bear, so I'm sharing it with you. But at this point in time, before I go on, and we're going to do each one, one by one, I just want to mention about the autonomic nervous system. So everything in the body is like a yang and a ying. If you think about the autonomic, you've got the sympathetic and you've got the parasympathetic. Famous board questions, and I don't know why they draw stick figures, and they draw neurons and then ask you what the neuro, I mean, you'd think with the money we pay for this that they'd be like really high end, like movies showing how this works. But they're stick figures. And so when you do the sympathetic, the pre-ganglionic, the neurotransmitter is always acetylcholine. The sympathetic post-receptors are norepinephrine, except for sweat glands, which are acetylcholine, but fall under the sympathetic. So when we do the parasympathetic, it's easier to remember. Pre-ganglionic is acetylcholine. Post-ganglionic is acetylcholine. So we talk about neurotransmitters, because the question will be if the drug knocks it out or keeps it going. So when I take the boards, I usually draw out my own little stick figures, and I put the neurotransmitters there so I can take a minute and think about it. Like, what are they asking me if the injury occurs here? And we'll give you examples of that as I go through this and in the neuro exam. So they love to ask about sympathetic blockade. We'll come back. That's just a hint. But anyway, so you look at this. You've all had time to memorize the chart. So we'll move on. So let me break it down line by line. So sympathomimetic, fight or flight. First thing I always remember is like, ah, your pupils are gigantic. You want to get the hell out of whatever's causing the problem. You're going to have an increased heart rate and blood pressure. Your temperature may go up, sympathomimetic. Respiratory rate, you may be it doesn't do anything directly. You may have an increased metabolic rate. You'll get a little tachypneic, perhaps. You can be agitated, hyperactive, paranoid. You may start out like that, but it may make bad worse. The pupils are big. So medriasis, you don't want to like at the last minute, oh my god, is it medriasis, meiosis? So just think big, it's like medriasis. And then the skin, they can be diaphoretic. So remember, it's sympathetic. So the sympathetic, the pre, is acetylcholine, the post. But because the exception is the sweat glands, so you've got acetylcholine. So I put that in there because you can have a good day and know 85% of what you need to know, and you don't know that one fun fact, and it kind of ruins your day. So anyway, and then you may see tremors. So the drugs to think about, cocaine, amphetamines, and cathions are sort of the bath salts because you can get them online. So you can go into New York, you can go into any bodega, and you can buy all of this stuff. It's there. Oh, seriously. I went in with a camera once, and the guy asked me to leave. I guess he thought I was like an undercover cop. I had a hoodie on, and I had my ID, so all he saw was the strap. He probably thought it was a badge. And I went to buy some of the stuff just to bring and take pictures. He wouldn't allow it. Anyway, but so you can get this stuff, and that's the problem because we can say, well, you know, it's sympathomimetic, I think. But K2, the new synthetic marijuana that's out there, has stuff added to it, and it can present as sympathomimetic. And when you send a drug stream, you don't get it. The street pharmacists are always one ahead of us. I don't know how they do it. Like, they change a methyl group this week. I'm like, wow, I don't know how you do that. You find a methyl group and change, but they do it. And, you know, it causes all kinds of problems. So, again, a lot of times we're going back to the sort of the physical exam with what we have. So I put sympathetic and anti-cholinergic together because they're simple. When they test things, they love to compare and contrast. So they always give you like two kids on a ventilator. You know, Andy is getting volume control, and his sister, Amaretta, is getting something else. And then they ask you what the difference is. So they love to mix and match. And when you read the symptoms they're giving you, you'll have to pick out which one is which. So if you go back, wow, the heart rate, the temperature, going to look the same. Respiratory rate is usually normal, usually. Mental status, agitated, mumbling, speech coma. The eyes are big, but here the skin is dry and flush, right? Because anti-cholinergic, the ACH, isn't getting to the sweat glands, even though the sympathetic is there, right? And then the acetylcholine, it needs to go everywhere else. So when I talk about acetylcholine, I always, succinylcholine is two acetylcholine molecules together. So if anybody's ever given a patient sucks, and you give, and you watch them do this, and then this, and then one of my patients, I'll leave out the F-bombs, but the next day he said, don't give me that same that I got in the ER yesterday, because it hurt. But you're giving a massive amount of acetylcholine. So if you're stopping the anti-choline, so we give a lot of acetylcholine, we get bradycardic. And that's the one fact I remember. I always walk my way back from that. So I'm giving you an anti-cholinergic. I'm not giving you the acetylcholine to slow your heart. It's gonna go faster. So that's why you see the tachycardia. So that's what I mean. These can be confusing, these toxidromes. So I always go back to the sympathetic, parasympathetic. I do this all the time. My kids think there's something wrong with me. But I'm always practicing how to do this. Anyway, so what drugs do we worry about for anti-cholinergic? We worry about antihistamines, Benadryl. We're gonna come back to Benadryl. You're gonna hear Benadryl a gazillion times. I already showed you the anti, you know, what do we do? For tricyclics, Benadryl, you know, we'll come back to it. Tricyclics, atropine, think about it, right? When you're, anesthesiologists are reversing somebody. If you give the Pfizer stigmine first and you stop the acetylcholinergic, the enzyme for breaking it down, they get a massive outpouring of acetylcholine that slows the heart. So when we get to the parasympathetic system, when we go down there, there's nicotinic receptors in the muscle and then there's smooth muscle receptors, the muscarinic. So if you give a lot of acetylcholine, it's like a wet syndrome because everything comes out and that's where sludge comes from. So we'll talk about sludge here. And again, later on for the anti-cholinergics. Phenothiazines and then the beladonna alkaloids. But again, they can look similar and it's subtle findings is how you're gonna make the difference. Some of us are better visual learners. So I found this online. So this is like in medical school, you always learn this one anti-cholinergic, right? Hot as a hair, dry as a bone, blah, blah, blah. So this is it and it sort of explains everything. And if you think about how the sympathetic and the parasympathetic works, the parasympathetic, you've got acetylcholine, acetylcholine, you stop the acetylcholine and these are the things that you're going to see. I just went through the tachycardia, but the flushed skin, the dry as a bone, we talked about looking at the mucosa. And again, I just put this in there because you got all these crazy challenges that come on the internet. And there were a whole bunch of reported deaths when this Benadryl challenge came out there. We saw a real tick up in it. So it's the kind of thing you see when you'll never forget it. Not everybody has taken care of somebody, but you want to think of the anticholinergic. So I'm always looking for ways for myself to remember and for you to remember. When you take the first board exam, they're testing how you think. When you take the MOC and everything else, they're seeing what we can still remember as we age. So it's a bit different. Now, so we did the two that looked alike. Now we're going to do cholinergic. Cholinergic, acetylcholine goes to acetylcholine. Acetylcholine goes to the muscles, causes muscle contraction, goes to the smooth muscles and causes them to do what they do. Again, later on, I've got pictures of all of this, schematically three different ways. So everybody gets it a different way. So hopefully, Meatloaf used to say two out of three ain't bad. So if I give you three, you should be okay. So the cholinergic we talked about, the heart rate goes down because you're given a lot of acetylcholine and we know that slows the heart down. It doesn't do much for temperature. Mental status, they can be lethargic because you've got acetylcholine in the brain as well as in the peripheral musculature, the neuromuscular junctions, and we'll spend a lot of time on that later. So the things that can cause this, fortunately, we don't see a lot of this, organophosphates, insecticide. However, as weapons of mass destruction, nerve agents is something that's up and about there. Anybody that works near a farm, like I work in the inner city Bronx, we worry about bullets, knives, and things like that. People 100 miles north have farms. They worry about organophosphate. Carbamates are the same way, but they don't get across the blood-brain barrier. Okay, so this is the cholinergic. So if you get a kid that's gotten a lot of cholinergic stimulation, they salivate, they lachrymate, they pee, they defecate, they got cramps. Everything comes out, right? So fight or flight, and this is sort of stay and eat, stay and do nothing. Always better to run than to stay, because you'll look like a mess, but anyway. I'm gonna leave this, because we're gonna come back to the organophosphates at one of the questions we're gonna do later. And then this is in another talk, so you've got it. So get to the opiates. What, Tom, just trying to look at the clock? I can skip some of my slides, because you have some there that are- Are the same? I think they are. Well, it gets good. It's getting later in the day, right? Okay, so let me just do the opiates. So all I'm doing is working through my toxidromes line by line. So if you look at the opiates, they can decrease the heart rate, they can cause hypothermia. So temperature, we talk at the vital signs, it's important. It might be the tip-off. Mental status, the pupils are small, pinpoint. So myotic pupils, as opposed to the midratic pupils, the myotic pupils, and you can lose your reflexes. But this is morphine, fentanyl, heroin, methadone. And remember, the urine talks that we send doesn't always test for all of these. You have to know the structures for each of these drugs. I'll give you two, I'm kidding. Lighten up, it's the end of the day. All right, so we're gonna skip the fentanyl for the sake of time. Sedatives, hypnotics, the benzos, and ethanol. I'm sure everyone in this room has had the ethanol effect, whether you'll admit it or not. Faculty will have it tonight at dinner. Okay, serotonin syndrome. Again, I'm gonna skip over this because there's three or four slides. This is one, if I had to pick the top five, I would pick calcium channel blockers, I'd pick sulfonylureas, I would pick beta blockers, and I would pick serotonin syndrome. I've given you all the spectrum of it, and what happens, and the drugs associated with it, and then how to tell them apart, right? So remember, she told you to memorize this, so if two people are telling you to memorize it, better chance it may happen. Everybody's praying that it doesn't. Hope is not a plan, just so you know. But anyway, you gotta tell them apart. And it's really based on time within 24 hours. And again, I'm gonna skip these. Key points for suscitations. Begins without knowing the exact intoxicant. Toxidromes may overlap in many times from the polyingestion. Infant children and not little adults will respond differently to what we do. Thank you, and I apologize for going over. That's a normal CAT scan, and that's a not so good one, we'll come back.

autonomic nervous system

neurotransmitters

toxidromes

serotonin syndrome

differential diagnosis