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The 2021 Core Content of Medical Toxicology


The Medical Toxicology Subboard approved modifications to the Core Content of Medical Toxicology in March 2021. The document outlines the areas of knowledge considered essential for the practice of medical toxicology. The Core Content provides the organizational framework for the development of the Medical Toxicology Certification and Cognitive Expertise Examinations and serves as a template for the development of curricula for medical toxicology fellowship training programs.


Contemporary medical curricula strive to “achieve a symbiosis with the health services and communities in which the students will serve” [1]. A “Core Content” document defines the essential body of knowledge for a given academic discipline and forms the basis for curriculum design, education, and testing.

In 1994, the Medical Toxicology Subboard (representing the American Board of Emergency Medicine, the American Board of Pediatrics, and the American Board of Preventive Medicine) developed the first Core Content of Medical Toxicology to inform the construction of the first certifying examination. This document consisted of 22 major content areas and was organized, in part, by toxicant classification. In 2000, and again in 2009, the Medical Toxicology Subboard convened a task force charged with updating the existing Core Content document, and to improve the framework that conceptualized the expanding body of knowledge of medical toxicology. These task forces solicited input from program directors for medical toxicology fellowship training programs and medical toxicology diplomates and established an ABEM contact and e-mail for recommendations about the Core Content from all medical toxicologists [2, 3]. The resulting version of the Core Content was published in 2012.

In 2020, the Medical Toxicology Subboard convened a task force charged with evaluating, refining, and updating the 2012 Core Content of Medical Toxicology. The 2020 Medical Toxicology Core Content Task Force was comprised of four board-certified medical toxicologists with specific content expertise in medical toxicology, pediatrics, environmental toxicology, emergency medicine, occupational toxicology, preventive medicine, poison center administration, emergency/disaster management, addiction medicine, and medical education. The task force members included current and former program directors from the US medical toxicology fellowship training programs, as well as staff members from the American Board of Emergency Medicine with expertise in psychometrics and examination design and development.

The 2020 task force considered the future needs of the specialty and recognized that a shortage of medical toxicologists currently exists. Many US academic and non-academic centers alike do not have medical toxicologists performing inpatient or outpatient consultations. As of 2020, the number of medical toxicology fellows enrolling in fellowship training programs is increasing; however, 25–33% of total positions in the country remain unfilled, and 33–50% of programs are unfilled each year [4]. The 2020 task force acknowledged that one way to encourage young physicians to consider careers in medical toxicology is to ensure that the Core Content remains current and relevant with regard to the current practice of medical toxicology.

In February 2021, the Medical Toxicology Subboard approved a revised Core Content document. The 2021 Core Content of Medical Toxicology encompasses the body of knowledge for the specialty of medical toxicology and outlines the areas of knowledge considered essential for its practice. The 2021 Core Content provides the organizational framework for the development of the Medical Toxicology Certification and Cognitive Expertise Examinations and details the knowledge to be tested beginning with the 2022 examination. In addition, the Core Content serves as a template for the development and application of curricula for fellowship training programs in medical toxicology. The current revision replaces the 2012 Core Content of Medical Toxicology.


The methodology applied in the development of the 2021 Core Content involved detailed analysis of the previous Core Content documents and ultimate consensus among the task force members. The work of the 2020 task force was informed by the knowledge that the Core Content is used by learners to direct their study, by program directors to direct their teaching, by test item writers to determine question topics, and by test designers to assemble the Certification and Cognitive Expertise Examinations.

The American Board of Emergency Medicine surveyed, via e-mail, 201 board-certified medical toxicologists with a wide variety of years-of-practice, practice setting, academic affiliation, medical publishing/research, involvement in teaching fellows, and poison center affiliation. Medical toxicologists rated how often each aspect of the 2012 Core Content was encountered and how important each item was to their current practice of medical toxicology. Survey respondents were also able to submit additional comments to inform this process. The survey was analyzed by the task force to identify areas for expanded or restricted detail. The task force expended in excess of 250 person-hours in the analysis and re-drafting of the Core Content.

The 2020 task force analyzed the 2012 Core Content document, which was organized into six subject areas: (1) principles of toxicology, (2) toxins and toxicants, (3) clinical assessment, (4) therapeutics, (5) assessment and population health, and (6) analytical and forensic toxicology. The 2020 task force expanded the “top-level” subject areas to include (7) environmental toxicology, (8) occupational and industrial toxicology, and (9) addiction toxicology and substance use. The intent was to improve the organization of the Core Content and to acknowledge the importance of these domains within the discipline of medical toxicology. The task force further sought to create a document that reflects current medical toxicology practice.

The Core Content was divided into sections for initial review by two task force members to recommend potential edits based on the guiding principles. Each recommendation was discussed by all four task force members, and the determination of consensus among task force members was used to finalize edits. Task force members then reviewed the entire document for consistency and presented the draft Core Content to the entire Medical Toxicology Subboard. After final editing and cross-referencing, the final Core Content document was approved by the Medical Toxicology Subboard.


The 2020 task force defined a set of “guiding principles” to be used in updating the Core Content, which included decreasing ambiguity and increasing the clarity and clinical relevance of the Core Content document.

Decreasing Ambiguity

The 2020 task force recognized that the Core Content may be used to design educational fellowship programs and to provide a guide for learners to organize their education and study. For this reason, the task force aimed to decrease ambiguities in the document. The task force drastically reduced the use of “examples” throughout the document to eliminate the implication that these “examples” were more important than other line items in a category. For example, the subsection that formerly listed “Specific radioisotopes (e.g., cesium, iodine, polonium, radon)” was updated to remove the “e.g.,” and now specifically lists the radioisotopes that a medical toxicologist should be familiar with and understand. This removes the implication that cesium, iodine, polonium, and radon are more important than others but also limits the number of clinically relevant radioisotopes that a medical toxicologist must master. Similarly, the task force decreased the use of the term “others” in the document, as this may imply that medical toxicologists must know all possible aspects of a topic and that any aspect of that topic may be a potential question on an examination. For example, in the section “metals/metalloids,” the metals and metalloids that are necessary to understand are specifically listed in place of “other.” As practice evolves, additional items may be added in subsequent revisions to the document. The Core Content is a guideline and, while no guideline encompasses every aspect of a topic, the task force felt that it was important to be specific when possible.

Increased Clarity

Revisions to some sections were made to specify the knowledge that a medical toxicologist should have about expansive topics. For example, “Role of the Medical Review Officer” was eliminated in favor of including additional topics under “interpretation of drug testing” that encompass aspects of the medical review officer role in current medical toxicology practice. Similarly, “confirmatory test; gas chromatography” was changed to “interpretation of confirmatory test results; gas chromatography” to de-emphasize the technical aspects of the test (i.e., how the lab performs the test) and emphasize the interpretation of the test and its advantages and limitations.

Clinical Relevance

A primary goal of the 2020 task force was to reorganize the Core Content focusing on clinical relevance. Certain sections were compressed and others were expanded to be more consistent with their relative weight in current medical toxicology practice. The task force added sections that have increasing importance in medical toxicology, including QRS prolongation, QTc prolongation, neonatal abstinence syndrome, epigenetics, and extracorporeal membrane oxygenation (ECMO). “Cannabis” was removed from the category “Psychoactive Drugs and Hallucinogens” and placed into its own category, given its prominence in the United States and the increasing legalization of cannabis.

The Occupational/Industrial Toxicology section was organized according to occupation and industry, with pertinent chemicals listed as subsections, because a medical toxicologist often evaluates workers from a particular occupation or industry (e.g., welder, painter, petrochemical industry worker) rather than with a specific chemical exposure (e.g., carbon disulfide exposure).

The task force further attempted to de-emphasize certain areas of the 2012 Core Content that were prone to esoterica. For example, the section “Regulatory and legal background (e.g., HAZWOPER, SARA, CERCLA, RCRA, etc.)” was removed; while the application of these laws may be integral to the practice of medical toxicology, the specifics of the law (wording, date of enactment, etc.) are de-emphasized. The task force removed “miscellaneous toxicants” and moved those chemicals to a new “occupational/industrial toxicology” section to more specifically contextualize them. Further, the 2020 task force agreed by consensus to eliminate from the Core Content document chemicals that have been banned or unavailable in the United States for at least 50 years and are not typically used internationally. These chemicals have been placed into the section entitled “Exposures of Historical Significance.”

The 2020 task force added three domains to the Core Content that reflect current medical toxicology practice: Environmental Toxicology, Occupational/Industrial Toxicology, and Addiction Toxicology. The intent of adding these sections was to reorganize existing sections of the Core Content and group them to more accurately reflect the current practice of the specialty of medical toxicology. Much of the content for these sections was contained in the 2012 Core Content document, but is re-organized to maximize clinical relevance.

The 2021 Core Content is intended to be a “living document,” in keeping with the evolving practice of medical toxicology. The Subboard anticipates periodic updates to the Core Content and recommends that these updates occur approximately every 5 years.

The 2021 Core Content of Medical Toxicology


1.1 Principles of Pharmacology/Toxicology

1.1.1 Pharmacokinetics/Toxicokinetics Bioavailability and absorption Clearance Distribution Elimination Metabolism Pharmacokinetic modeling

1.1.2 Pharmacodynamics/Toxicodynamics Dose/Concentration relationship to effect Receptor agonism/Antagonism Receptor regulation Structure-activity relationship

1.1.3 Adverse drug effect

1.1.4 Interactions Drug-drug Xenobiotic

1.1.5 Immunologic response

1.1.6 Pharmacogenetics/Toxicogenetics Polymorphisms causing adverse effects

1.2 Principles of Molecular Components/Mechanisms

1.2.1 Ion channels and ion pumps

1.2.2 Enzymes and transport proteins

1.2.3 Glycolysis and oxidative phosphorylation

1.2.4 Membranes

1.2.5 Neurotransmitters (see 8.4)

1.3 Principles of Radiation

1.4 Principles of Mutagenesis and Carcinogenesis

1.4.1 Mutagenesis

1.4.2 Carcinogenesis Procarcinogens Initiation Progression Promotion

1.5 Principles of Epigenetics

1.6 Principles of Reproductive and Developmental Toxicology

1.6.1 Conception impairment/Mutagenesis/Teratogenesis

1.6.2 Pharmacology of pregnancy

1.6.3 Factors determining fetal or infant exposure to agents Placental transfer Fetal pharmacokinetics Breast milk transfer

1.6.4 Pharmacology of the neonate


2.1 Medications and Drugs

2.1.1 Analgesics/Anti-inflammatory drugs Acetaminophen NSAIDs Opioids (see 3.1.3) Salicylates Colchicine

2.1.2 Antimicrobials Antibiotics (see Antifungals Antimycobacterials Antiparasitics Antiprotozoals Antiretrovirals Antiseptics Antivirals

2.1.3 Chemotherapeutic drugs Alkylators Antimetabolites Hormones Antimitotics Monoclonal antibodies Platinum-based Protein kinase inhibitors Topoisomerase inhibitors

2.1.4 Diagnostic contrast agents

2.1.5 Drugs affecting lipids

2.1.6 Drugs affecting the cardiovascular system Cardiovascular Calcium channel blockers Cardioactive steroids Potassium channel blockers Sodium channel blockers Antihypertensives Angiotensin system modulators Peripheral alpha antagonists Beta adrenergic antagonists Centrally acting alpha receptor agonists Diuretics Vasodilators

2.1.7 Drugs affecting the respiratory system Bronchodilators and respiratory stimulants Antitussives and cold preparations

2.1.8 Drugs affecting the endocrine system Antidiabetic drugs Drugs affecting bone metabolism Electrolytes and minerals Glucocorticoids Sex hormones/Growth hormones/Anabolic steroids Thyroid drugs Vasopressin and somatostatin analogues

2.1.9 Drugs affecting the gastrointestinal system Antidiarrheals Antiemetics Drugs used for biliary and pancreatic diseases Drugs used for inflammatory bowel disease Drugs used to treat esophageal-peptic disorders Laxatives Promotilics

2.1.10 Drugs that affect the hematologic system Anticoagulants Antifibrinolytics Antiplatelet drugs Bone marrow stimulating drugs Drugs used to treat bleeding Iron Thrombolytics

2.1.11 Drugs that affect the immune system Corticosteroids Immunosuppressants Biologics

2.1.12 Drugs that affect the nervous system Anesthetics Inhalational and sedative anesthetics Local anesthetics Anticonvulsant drugs Antiparkinsonism drugs Drugs that affect autonomic homeostasis Anticholinergics (see 3.1.1) Antihistamines Antiserotonergics Cholinergics (see 3.1.2) Ergot and derivatives Serotonin agonists and proserotonergics      (see 3.1.5) Ethanol Muscle relaxants Neuromuscular blockers Psychoactive drugs and hallucinogens Psychotropics Antidepressants Antipsychotics Anxiolytics and sedative-hypnotics Mood stabilizers

2.1.13 Pharmaceutical excipients/Diluents/Solvents

2.1.14 Veterinary products

2.1.15 Abortifacients

2.1.16 Drugs of abuse (see 8.2 and 8.8) CNS depressants Dissociatives Hallucinogens Cannabis/Cannabinoids Inhalants Opioids Sympathomimetics Diluents/Adulterants/Contaminants Novel psychoactive substances

2.2 Household Items

2.2.1 Cleansers and caustics Acids Alkali Bleach Detergents and soaps Disinfectants and topical anti-infectives Hydrogen peroxide Potassium permanganate

2.2.2 Swimming pool products Chlorine Bromine

2.2.3 Aquarium products

2.2.4 Art products

2.2.5 Batteries

2.2.6 Cosmetics

2.2.7 Dental products

2.2.8 Hair products

2.2.9 Personal hygiene products

2.2.10 Automotive products

2.2.11 Household pesticides DEET Moth repellents Pyrethrins and pyrethroids

2.2.12 Household rodenticides Hydroxycoumarins and inandiones Bromethalin

2.3 Supplements

   2.3.1 Herbal products

   2.3.2 Performance enhancing substances

   2.3.3 Dietary supplements

   2.3.4 Vitamins

2.4 Food Poisoning

   2.4.1 Bacterial toxins

   2.4.2 Botulism Infant Food-borne

2.4.3 Marine toxins Ciguatera Scombroid Tetrodotoxin Shellfish poisonings Amnestic Paralytic Neurotoxic

2.5 Fungi

2.5.1 Mushrooms Cyclopeptide Gyromitrin Muscarine Coprine Ibotenic acid and muscimol Psilocybin Gastrointestinal toxic Orellanine Allenic norleucine Lycoperdon

2.5.2 Fungal toxins Aflatoxins Trichothecene mycotoxins

2.6 Plants

2.6.1 Cutaneous/Mucous membrane

2.6.2 Toxalbumins

2.6.3 Sodium channel activators

2.6.4 Pyrrolizidine alkaloid

2.6.5 Nicotine-like

2.6.6 Mitotic inhibitors

2.6.7 Gastrointestinal toxins

2.6.8 Cyanogenic

2.6.9 Convulsant

2.6.10 Cardioactive steroids

2.6.11 Calcium oxalate

2.6.12 Anticholinergic

2.7 Envenomations

2.7.1 Arthropods Hymenoptera Scorpions Spiders

2.7.2 Marine Animals

2.7.3 Reptiles Venomous snakes Hemotoxic Neurotoxic Cytotoxic Venomous lizards

2.7.4 Amphibians

2.8 Agents of Warfare/Terrorism

2.8.1 Biological Bacteria Toxins Viruses

2.8.2 Chemical Nerve agents Blister agents/Vesicants Systemic agents/Asphyxiants Irritant/Corrosive Incapacitating agents Riot control agents (see Opioids

2.9 Radiological

2.9.1 Radiation sources

2.9.2 Specific radionuclides Americium Cesium Cobalt Iodine Plutonium Polonium Radium Strontium Thorium Uranium


3.1 Toxicologic Syndromes

3.1.1 Anticholinergic (see

3.1.2 Cholinergic (see

3.1.3 Opioid (see

3.1.4 Sedative-hypnotic

3.1.5 Serotoninergic (see

3.1.6 Sympathomimetic

3.2 Differential Diagnosis

3.2.1 Cardiovascular Blood pressure Heart rate Oxygenation Electrocardiographic Dysrhythmias QRS prolongation QT prolongation

3.2.2 Dermatologic Skin color abnormality Hair and nail abnormalities Rash and other cutaneous reactions

3.2.3 Gastrointestinal Diarrhea/Constipation GI hemorrhage Hepatic dysfunction Pancreatitis Vomiting

3.2.4 Hematologic Red blood cell abnormalities White blood cell abnormalities Hemostatic disorders

3.2.5 Musculoskeletal Rhabdomyolysis Skeletal abnormalities

3.2.6 Neurologic Ataxia Delirium Altered mental status Headache Movement disorder Neuropathy/Paresthesia Rigidity Seizure Tremor Weakness/Paralysis

3.2.7 Psychiatric Agitation Depression Hallucinations Psychosis

3.2.8 Pulmonary Cough Pulmonary edema/Acute lung injury Restrictive lung disease Smoke inhalation Wheezing/Bronchospasm

3.2.9 Renal/Genitourinary Kidney injury Nephritis/Nephrosis Obstruction/Renal stone Fertility abnormalities Sexual dysfunction

3.2.10 Ophthalmologic Vision loss/Changes Pupil changes Nystagmus

3.2.11 Otologic Hearing loss Tinnitus

3.2.12 Pediatric and Reproductive Syndromes Fetal abnormalities Fetal alcohol syndrome Fetal hydantoin syndrome Fetal valproate syndrome Fetal warfarin syndrome Fetal aminopterin/Methotrexate syndrome Retinoic acid embryopathy Thalidomide embryopathy Fetal solvent syndrome Developmental disorders Child abuse

3.3 Exposures of Historical Significance


4.1 Initial Management

4.1.1 Decontamination strategies Dermal Gastrointestinal Ocular

4.1.2 Enhanced elimination techniques Extracorporeal removal Multi-dose activated charcoal Urinary clearance

4.1.3 Pharmacological basis of antidote use Amyl and sodium nitrite Botulinum antitoxin Bromocriptine Calcium L-carnitine Cyproheptadine Dantrolene Deferoxamine Digoxin-specific fab Dimercaprol Ca- and Zn-DTPA Edetate calcium disodium Ethanol Flumazenil Folinic acid (leucovorin) Fomepizole Glucagon Glucarpidase Hydroxocobalamin Hyperbaric oxygen Intravenous lipid emulsion Latrodectus antivenom Methylene blue Naloxone N-acetylcysteine North American crotalidae polyvalent fab North American crotalidae F(ab’)2 North American coral snake antivenom Octreotide Physostigmine Potassium iodide Pralidoxime Protamine Prussian blue Pyridoxine Scorpion (centruroides) antivenom F(ab’)2 Sodium bicarbonate Sodium thiosulfate Succimer (2,3-dimercaptosuccinic acid) Thiamine Uridine triacetate Vitamin K1

4.1.4 Supportive and other care Airway management/Oxygenation/Ventilation Anticonvulsants Antidysrhythmics Control of agitation Control of blood pressure and heart rate Control of temperature Correction of electrolyte and acid-base disturbances Transplantation Extracorporeal membrane oxygenation

4.1.5 Radiation exposure management Dosimetry Decontamination Chelation therapy


5.1 Causation

5.1.1 Bradford Hill associations

5.2 Principles of Epidemiology and Study Design

5.2.1 Poisoning epidemiology and study design

5.2.2 Study design Study types Grading of scientific evidence Non-human studies Observational studies Clinical trials Validity and generalizability

5.2.3 Statistical measures Statistical power and sample size Measures of association Test characteristics Sensitivity/Specificity Predictive values Likelihood ratios

5.3 Poison Centers

5.3.1 Administration/Organization

5.3.2 Data collection systems

5.3.3 Surveillance/Interaction with other professional health organizations

5.4 Response to Hazardous Materials (Hazmat) Incidents/Terrorism

5.4.1 Scene decontamination

5.4.2 Incident command system and control zones

5.4.3 Hazardous Materials Resources (e.g., Strategic National Stockpile, CHEMPACK program)

5.4.4 Clandestine drug laboratories

5.5 Regulatory and Legal Background

5.5.1 Role of federal and international agencies in toxicology Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) National Institute for Occupational Safety and Health (NIOSH) Consumer Product Safety Commission (CPSC) Drug Enforcement Administration (DEA) Definition and scheduling of controlled substances Environmental Protection Agency (EPA) Food and Drug Administration (FDA) Risk evaluation and mitigation strategies Health Resources and Services Administration (HRSA) Occupational Safety and Health Administration (OSHA) World Health Organization (WHO) International Agency for Research on Cancer (IARC)

5.6 Injury Prevention

5.6.1 Poisoning prevention

5.6.2 Medication safety Adverse event/Adverse reaction/Medication error Stages of medication use Error reduction strategies


6.1 Drug Testing

6.1.1 Interpretation of drug tests (see 8.6) Immunoassays Colorimetric tests Atomic absorption Gas chromatography/Mass spectrometry (GC/MS) High-pressure liquid chromatography (HPLC)

6.1.2 Urine drug testing Analytical limitations and interferences Interpretation of urine drug tests (see 8.6) False positives and false negatives Passive exposure to drugs of abuse

6.1.3 Additional testing matrices Meconium Vitreous humor Hair

6.1.4 Laboratory quality assurance/Quality control (e.g., CLIA)

6.1.5 Workplace drug and alcohol testing Interpretation of workplace drug testing Drug tests and impairment Cutoffs Adulterants/Diluents/Substitutions Principles of workplace drug testing Federal drug and alcohol testing rules

6.1.6 Drug testing in non-workplace settings

6.1.7 Forensic toxicology Postmortem specimens Selection of specimens Interpretation Redistribution Chain of custody Medical legal issues Role of expert witness Ethical standards for testimony Standards of reliability Daubert and Frye standards Legal aspects of ethanol and drugs of abuse Ethanol and drug-induced psychomotor impairment Collection/Storage/Interpretation of specimens Pharmacokinetics of ethanol and drugs of abuse Analysis Saliva Blood Breath Specific substances Ethanol Cannabis


7.1 Background

7.1.1 Precautionary principle

7.1.2 Vulnerable populations

7.2 Chemical and Physical Exposures

7.2.1 Air pollutants Sources of air pollution Specific pollutants EPA criteria air pollutants (see 9.4.1 and 9.4.2) Carbon monoxide Oxides of nitrogen Ozone Particulate matter (PM2.5 & PM10) Sulfur dioxide Volatile organic compounds EPA hazardous air pollutants Indoor air pollutants Radon Tobacco smoke Volatile organic compounds
 Tight-building syndrome Mold

7.2.2 Water and soil pollutants Sources and sites of pollutants Specific water and soil pollutants Metals/Metalloids (see Pesticides/Insecticides (see and Fungicides (see Herbicides (see Fertilizer (Nitrate/Nitrite) Perfluoroalkyl substances (PFAS) Persistent organic pollutants Dichlorodiphenyltrichloroethane (DDT) Polychlorinated biphenyls (PCB) Polychlorinated dibenzo-p-dioxins (PCDD/Dioxins) Polychlorinated dibenzofurans (PCDF) Petroleum-related Gasoline and additives Fracking Perchlorates

7.2.3 Food and drinking water toxicants Food safety Fish-related Bioaccumulation and biomagnification Specific pollutants Mercury (see Polychlorinated biphenyls (PCBs) (see Specific food/Drinking water additives and contaminants Metals/Metalloids (see Antibiotics (see Monosodium glutamate Endocrine-disrupting chemicals Bisphenols Phthalates (see Pesticides (see Fluoride

7.2.4 Symptoms attributed to the environment Multiple chemical sensitivity Gulf War Syndrome World Trade Center Health Program covered conditions

7.3 Natural Radiation Exposures


8.1 Definitions

8.1.1 Addiction

8.1.2 Dependence

8.1.3 Withdrawal

8.1.4 Tolerance

8.1.5 Hyperalgesia

8.2 Clinical Pharmacology of Drugs of Abuse (see 2.1.16)

8.2.1 Ethanol

8.2.2 Sedatives and GABA agents

8.2.3 Opioids/Opiates

8.2.4 Stimulants

8.2.5 Nicotine and tobacco

8.2.6 Cannabinoids

8.2.7 Hallucinogens

8.2.8 Dissociatives

8.2.9 Inhalants

8.3 Neurobiology of Addiction

8.4 Neuropharmacology of Addiction (see 1.2.5)

8.4.1 Acetylcholine

8.4.2 Norepinephrine

8.4.3 Dopamine

8.4.4 Serotonin

8.4.5 GABA

8.4.6 NMDA and glutamate receptors

8.4.7 Endogenous opioids

8.4.8 Endocannabinoids

8.5 Screening, Assessment, and Brief Intervention

8.6 Interpretation of Drug Testing (see 6.1.1 and

8.7 Addiction Treatment

8.7.1 Alcohol use disorder

8.7.2 Substance use disorders Pharmacologic intervention for substance use disorders Opioid use disorder Buprenorphine Methadone Naltrexone Other substance abuse disorders

8.7.3 Behavioral interventions

8.8 Management of Intoxication From Substance Use (see 2.1.16)

8.9 Management of Withdrawal of Substance Use

8.9.1 Ethanol

8.9.2 Sedative-hypnotics

8.9.3 Nicotine

8.9.4 Opioids

8.9.5 Stimulants

8.9.6 Neonatal abstinence syndrome


9.1 Occupational Assessment and Prevention

9.1.1 Medical surveillance and pre-placement screening

9.1.2 Exposure control Engineering controls Personal protective equipment Work practices and product substitution

9.2 Occupational Monitoring

9.2.1 Biological monitoring and biomarkers

9.2.2 Environmental sampling/Exposure monitoring

9.3 Risk Assessment and Risk Management

9.3.1 Hazard identification

9.3.2 Dose response assessment No observed adverse effect levels (NOAEL) Lowest observed adverse effect levels (LOAEL) Benchmark dose Uncertainty factors

9.3.3 Exposure assessment Exposure pathways Interpretation of limit values Recommended Exposure Limit (REL) Permissible Exposure Limit (PEL) Threshold Limit Value (TLV)

9.3.4 Risk characterization

9.3.5 Risk perception and risk communication

9.4 Industrial Toxicants

9.4.1 Cellular asphyxiant gases (see Carbon monoxide Cyanide Hydrogen sulfide

9.4.2 Irritant gases (see Chlorine Nitrogen oxides Ozone Phosgene Sulfur oxides

9.4.3 Simple asphyxiants

9.5 Occupational Toxicants

9.5.1 Airborne solids Asbestos (see Coal dust (see Organic dust Silica (see Synthetic mineral fibers

9.5.2 Hydrocarbons/Solvents/Fuels Aldehydes Acetaldehyde Formaldehyde Acrolein Alcohols and glycols Diethylene glycol Ethylene glycol Glycol ethers Isopropanol Methanol Aliphatic hydrocarbons (see Hexane (see Gasoline Kerosine Aromatic hydrocarbons (see Benzene Polycyclic aromatic hydrocarbons Toluene Halogenated hydrocarbons Carbon tetrachloride Chloroform Methylene chloride Perchloroethylene Trichloroethylene Vinyl chloride (see and Hydrazines (see Ketones Methyl ethyl ketone Diacetyl Acetone Peroxides (see Hydrogen peroxide Sodium peroxide Metals/Metalloids (see,,,, and Aluminum Antimony Arsenic Barium (see Beryllium Cadmium Chromium Cobalt Copper Lead Manganese Mercury (see and Nickel Silver Thallium (see Zinc Pesticides (see,, and Fumigants (see Fungicides (see Herbicides (see Insecticides and repellents (see Carbamates Organochlorines Organophosphates Pyrethrins and pyrethroids Occupational rodenticides Coumarins and inandiones Sodium monofluoroacetate (SMFA) Zinc phosphide Arsenic trioxide Barium (see Tetramine Cholecalciferol Bromethalin Alpha-Naphthylthiourea (ANTU) Thallium (see Yellow phosphorus Strychnine Molluscicides

9.5.3 Nanotoxicology

9.6 Toxicants Associated with Specific Industry Exposures, Not Listed Elsewhere

9.6.1 Construction industry Carpentry and woodworking Paint/Painters Welding and metal joining Metal fume fever Metals/Metalloids (see Roofing and road building Coal tar and pitch

9.6.2 Chemical industry Chemical manufacturing Acrylamide Acrylonitrile Vinyl chloride (see and Ethylene oxide (see Polytetrafluoroethylene/Polymer fume fever Pharmaceutical manufacturing Dimethylformamide Ethylenediamine Isocyanates (see 9.4.2)

9.6.3 Cosmetology/Hair Paraphenylenediamine Perborates

9.6.4 Dry cleaning industry Trichloroethylene Perchloroethylene/Tetrachlorethylene

9.6.5 Explosives/Munitions/Fireworks manufacturing industry Dinitrotoluene Dinitrobenzene Chlorates Phosphorous Metals/Metalloids (see

9.6.6 Agricultural/Farming industry Pesticides (see Fumigants (see Manure pits (see Silos

9.6.7 Law enforcement/Military/Firefighting/EMS Combustion toxicology Riot control agents/Tear gas (see

9.6.8 Aerospace industry Jet fuels Hydrazine rocket fuel (see

9.6.9 Artists and artisans Metals/Metalloids (Lead/Cadmium/Manganese/Cobalt) (see Solvents/Paint strippers Hydrofluoric acid (see

9.6.10 Health care Acrylates Ethylene oxide (see Nitrous oxide Mercury amalgam (see

9.6.11 Mining industry Coal dust (see Asbestos (see Silica (see

9.6.12 Petrochemical industry Aliphatic and aromatic hydrocarbons (see and

9.6.13 Plastics/Epoxy/Resins/Rubber manufacturing Plastics and foams Phthalates (see Vinyl chloride (see and 1,3-butadiene Dimethylformamide Organotins Epoxy and resins Epichlorohydrin Trimellitic anhydride Maleic anhydride Rubber manufacturing Ethylbenzene Butadiene Thiurams Dithiocarbamates

9.6.14 Pulp/Paper/Timber industry Peroxides (see Mercaptans Wood dust

9.6.15 Sanitation and sewer treatment Hydrogen sulfide (see

9.6.16 Semiconductor industry Fluorides Arsine/Stibine Phosphine Diborane Tetramethylammonium hydroxide Dichlorosilane/Trichlorosilane

9.6.17 Manufacture of ships and automobiles Styrene Sodium azide

9.6.18 Smelting/Metal refining/Reclamation Hydrofluoric acid (see Metals/Metalloids (see

9.6.19 Textile industry n-hexane (see Cotton dust Carbon disulfide Dyes Aniline Benzidine Beta-naphthylamine Xylidine


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The 2020 Medical Toxicology Core Content Task Force wishes to gratefully acknowledge the review of the 2021 Core Content document by the members of the Medical Toxicology Subboard (Diane P. Calello, M.D.; Christopher O. Hoyte, M.D.; Tammi H. Schaeffer, D.O.; Joshua G. Schier, M.D.; and Andrew I. Stolbach, M.D.).

Medical Toxicology Core Content Task Force members are Robert G. Hendrickson, M.D., Chair; Theodore C. Bania, M.D.; Carl R. Baum, M.D.; and Michael I. Greenberg, M.D., MPH, and American Board of Emergency Medicine (Kevin B. Joldersma, Ph.D., and Julia N. Keehbauch).

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The Core Content of Medical Toxicology is used with the permission of the American Board of Emergency Medicine, the American Board of Pediatrics, and the American Board of Preventive Medicine, copyright 2021.



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Correspondence to Julia N. Keehbauch.

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Robert G. Hendrickson, Theodore C. Bania, Michael I. Greenberg, Kevin B. Joldersma, and Julia N. Keehbauch declare no competing interests. Carl R. Baum receives personal fees from Elsevier, Wolters Kluwer, the American Board of Pediatrics, the American College of Medical Toxicology, Attorney Michael Foley, Cheshire, CT, the University of Connecticut, and FMAS Corp, and non-financial support from Wolters Kluwer, the American Board of Pediatrics, the American Academy of Pediatrics, the American College of Medical Toxicology, and the US Department of Health and Human Services.

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Supervising Editor: Mark B. Mycyk, MD

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Hendrickson, R.G., Bania, T.C., Baum, C.R. et al. The 2021 Core Content of Medical Toxicology. J. Med. Toxicol. 17, 425–436 (2021).

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  • Core Content
  • Medical Toxicology
  • Toxicology
  • Curriculum