Critical Care Time 72. ICU Toxicology with Dr. Adam Mora
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Mar 23, 2026 Dr. Adam Mora, an intensivist and clinical toxicology educator, guides a case‑based tour of ICU toxicology. He covers opioid overdose management and naloxone strategies. Airway and sedation decisions after overdose are discussed. Recognition and treatment of serotonin syndrome and other hyperthermic toxidromes are reviewed. Practical guidance on toxic alcohols, lithium, TCA and bupropion toxicities, dialysis indications, and system‑level planning is provided.
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Xylazine Explains Naloxone 'Failures' With Fentanyl
- Xylazine (tranq) commonly coingests with fentanyl and causes profound sedation, bradycardia, hypotension, and necrotic skin lesions that naloxone won't reverse.
- Suspect xylazine when naloxone gives incomplete or transient response and examine skin for ulcers.
Dose Naloxone Infusion From The Effective Bolus
- When starting a naloxone infusion, calculate two-thirds of the total effective IV bolus that produced adequate ventilation and use that (mg/hr) as the infusion rate.
- Remember naloxone half-life is 30–90 minutes and reversal may take 12–48 hours for some overdoses.
Clonus Is The Diagnostic Clue For Serotonin Syndrome
- Clonus, hyperreflexia, mydriasis, autonomic instability and rapid onset after serotonergic drug change point to serotonin syndrome; Hunter criteria emphasize clonus as key.
- Ocular or inducible ankle clonus plus agitation/diaphoresis is diagnostic in context of serotonergic exposure.