Study guide
11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment
Key Takeaways Explain This Topic AI
Neuroleptic malignant disorder is a separately enumerated blueprint subsection under Psychiatry.
Serotonin syndrome develops within hours with hyperreflexia, clonus and mydriasis, whereas neuroleptic malignant syndrome develops over days with lead-pipe rigidity and hyporeflexia.
Serotonin syndrome is treated with cessation, benzodiazepines and cyproheptadine, while neuroleptic malignant syndrome is treated with dantrolene and dopamine agonists.
Access to firearms is the strongest modifiable determinant of suicide lethality and must be asked about directly.
Asking about suicidal ideation does not increase risk and is a required element of the assessment.
Last updated: August 2026
- 1. Acute Psychiatric Toxic Emergencies: Serotonin Syndrome & NMS
- 1. Serotonin Syndrome (Serotonin Toxicity)
Pathophysiology: Excessive stimulation of central and peripheral 5-HT 1A and 5-HT 2A receptors .
Culprit Drug Combinations: SSRIs, SNRIs, MAOIs, TCAs, Tramadol , Meperidine , Methadone, Dextromethorphan , Linezolid (oxazolidinone antibiotic with intrinsic MAOI activity), Methylene Blue , MDMA (Ecstasy) , Triptans , and St. John's Wort.
Hunter Serotonin Toxicity Criteria (Gold Standard): In the presence of a serotonergic agent, diagnosis requires at least one of the following:
- Spontaneous clonus
- Inducible clonus PLUS agitation or diaphoresis
- Ocular clonus (slow, continuous, horizontal roving eye movements) PLUS agitation or diaphoresis
- Tremor PLUS Hyperreflexia
- Hypertonia PLUS Temperature > 38.0°C PLUS ocular or inducible clonus
Clinical Manifestations: Acute onset (<24 hours); triad of:
Neuromuscular Excitation: Marked lower-extremity hyperreflexia (3-4+) , spontaneous/inducible/ocular clonus, tremor, shivering, bilateral Babinski signs.
Autonomic Hyperactivity: Hyperthermia, profuse diaphoresis, facial flushing, tachycardia, labile hypertension, mydriasis, hyperactive bowel sounds with watery diarrhea .
Altered Mental Status: Severe agitation, restlessness, akathisia, delirium, confusion.
Emergency Management:
Immediately discontinue all serotonergic pharmacotherapies.
Aggressive supportive care: IV crystalloids, continuous cardiac monitoring.
IV Benzodiazepines (Diazepam 5-10 mg or Lorazepam 2-4 mg): Essential first-line therapy to control psychomotor agitation, blunt autonomic surge, and reduce muscle-generated hyperthermia.
Specific Antidote (Cyproheptadine): First-generation 5-HT 2A antagonist; administer oral/NG initial dose of 12 mg , followed by 2 mg every 2 hours if symptoms persist, then maintenance 8 mg every 6 hours .
Severe Hyperthermia (Temp >41.1°C / 106°F): Emergency endotracheal intubation, neuromuscular paralysis with non-depolarizing agents ( Vecuronium ; avoid Succinylcholine due to hyperkalemia and rhabdomyolysis risk), and ICU admission.
2. Neuroleptic Malignant Syndrome (NMS)
Pathophysiology: Acute, profound blockade of central Dopamine D2 receptors in the corpus striatum (causing rigidity) and hypothalamus (causing hyperthermia), or abrupt withdrawal of dopaminergic agonists (e.g., Levodopa, Bromocriptine) in Parkinson's disease.
Culprit Agents: High-potency typical antipsychotics ( Haloperidol, Fluphenazine ), low-potency (Chlorpromazine), atypical antipsychotics ( Risperidone, Olanzapine, Quetiapine ), and antiemetics ( Metoclopramide, Prochlorperazine, Promethazine ).
Diagnostic Clinical Tetrad:
Hyperthermia: Temperature typically > 38.0°C to 40.5°C (100.4°F to 105°F).
Severe Muscle Rigidity: Generalized "Lead-pipe" rigidity across all muscle groups, accompanied by hyporeflexia and bradykinesia (distinguishes NMS from the hyperreflexia and clonus of Serotonin Syndrome).
Altered Mental Status: Encephalopathy, mutism, stupor, catatonia, fluctuating delirium, coma.
Autonomic Instability: Tachycardia, labile blood pressure, tachypnea, profuse diaphoresis, pallor, sialorrhea (drooling).
Laboratory Hallmark: Markedly elevated Serum Creatine Kinase (CK > 1,000 to >100,000 IU/L) , profound leukocytosis (WBC 10,000-40,000/mcL), elevated transaminases, metabolic lactic acidosis, and myoglobinuria leading to acute tubular necrosis / acute kidney injury .
Emergency Management:
Immediately discontinue all antipsychotics / neuroleptic agents (or immediately restart dopamine agonists if precipitated by Parkinson medication withdrawal).
Emergent transfer to the Intensive Care Unit (ICU).
Aggressive IV crystalloid hydration ( target urine output >2 mL/kg/h ) with urine alkalinization to prevent myoglobinuric acute renal failure.
Active external cooling blankets and ice packs.
IV Benzodiazepines (Lorazepam 1-2 mg IV q4-6h): Reduces rigidity and controls autonomic instability.
Specific Pharmacologic Antidotes:
Dantrolene Sodium: Direct-acting skeletal muscle relaxant; blocks ryanodine receptors on the sarcoplasmic reticulum, inhibiting calcium release. Dose: 1 to 2.5 mg/kg IV bolus , repeated up to a maximum of 10 mg/kg/day; taper to oral after clinical improvement.
Bromocriptine Mesylate: Central dopamine D2 receptor agonist. Dose: 2.5 to 5 mg PO/NG TID , titrated up to 15-45 mg/day.
Amantadine: Dopaminergic and NMDA antagonist. Dose: 100 mg PO BID , titrated to 200 mg BID.
2. Comprehensive Suicide Risk Assessment & Clinical Safety Management
Suicide is a major public health crisis and a leading cause of premature mortality. Every primary care and hospital physician must conduct structured suicide risk evaluations.
- Static vs. Dynamic Suicide Risk Factors Suicide Risk Factor Stratification Matrix
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STATIC (NON-MODIFIABLE) RISK FACTORS:
- PRIOR SUICIDE ATTEMPT: The single strongest clinical predictor of completed suicide.
- Family History: Completed suicide in a first-degree relative.
- Demographics: Male sex (completes suicide 3-4x more often than females due to lethal methods);
Older age (men >=65 years have highest demographic rate); Caucasian or Native American.
- Chronic Medical Illness: Terminal cancer, chronic intractable pain, severe neurological disease.
- Childhood Trauma: History of severe physical, emotional, or sexual abuse.
DYNAMIC (MODIFIABLE & ACUTE) RISK FACTORS:
- ACTIVE SUICIDAL INTENT & SPECIFIC PLAN: Defined method, timing, and preparation.
- ACCESS TO LETHAL MEANS: Firearms in the home, stockpiles of lethal medications.
- Severe Hopelessness & Despair: Strongest cognitive predictor of imminent suicidal behavior.
- Acute Intoxication / Active Substance Abuse: Impairs impulse control and judgment.
- Acute Psychosis: Command auditory hallucinations instructing self-harm.
- Severe Agitation, Psychomotor Restlessness, & Severe Intractable Insomnia.
- Acute Precipitating Crisis: Major interpersonal loss, divorce, financial ruin, legal crisis.
- Lack of Social Support / Social Isolation.
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- Clinical Management & Lethal Means Restriction
Lethal Means Restriction (Critical Board Intervention):
Firearms: The presence of a firearm in the home increases the risk of suicide by 3 to 5-fold for all household members. Physicians must explicitly ask every suicidal patient about firearms in the home and counsel family members to safely lock, remove, or transfer firearms to law enforcement or trusted relatives outside the home.
Medications: Securely lock all household medications; prescribe only small, non-lethal quantities (e.g., 7-day supplies) with blister packaging; immediately dispose of unused opioids, sedatives, and TCAs.
Evidence-Based Safety Planning Intervention (SPI):
A collaborative, written, 6-step personalized safety plan identifying: (1) Personal warning signs of impending crisis, (2) Internal coping strategies (exercise, mindfulness), (3) Social distractions and social contacts, (4) Family members/friends who can help in crisis, (5) Professional mental health contacts and emergency services, and (6) Lethal means restriction steps.
Provide the National Suicide & Crisis Lifeline (Dial 988) and local crisis center numbers.
Triage & Disposition Decision Algorithm:
High Imminent Risk: Active suicidal ideation with specific intent, lethal plan, accessible lethal means, severe agitation/psychosis, or refusal to collaborate with safety plan.
Action: Mandates immediate inpatient psychiatric hospital admission .
Voluntary vs. Involuntary Admission: Always attempt voluntary hospitalization first. If the patient refuses and insists on leaving, the physician has an absolute legal and ethical duty to initiate an Emergency Involuntary Psychiatric Hold / Detention to secure patient safety. The patient must NEVER be left unattended.
Moderate / Low Risk: Passive suicidal ideation without intent or plan, strong social support, intact impulse control, future-oriented mindset, and reliable collaboration with safety plan.
Action: Safe for outpatient management with urgent (within 24-48 hours) psychiatric follow-up, lethal means removal verified with family, and 24/7 crisis numbers provided.