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