Anticholinergic toxicity: Difference between revisions
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==Treatment== | ==Treatment== | ||
#GI decon | #GI decon | ||
##Activated | ##[[Activated Charcoal]] may be effective even >1hr after ingestion (decreased GI motility) | ||
#Sedation | #Sedation | ||
##Decreases the risk of hyperthermia, rhabdo, traumatic injuries | ##Decreases the risk of [[hyperthermia]], [[rhabdo]], traumatic injuries | ||
##Benzos are agents of choice | ##[[Benzos]] are agents of choice | ||
#Cholinesterase inhibition | #Cholinesterase inhibition | ||
##Indicated for severe agitation or delirium (esp if unresponsive to benzos) | ##Indicated for severe agitation or delirium (esp if unresponsive to [[benzos]]) | ||
##Avoid when cardiac conduction abnormalities are present | ##Avoid when cardiac conduction abnormalities are present | ||
##Physostigmine | ##Physostigmine | ||
Revision as of 06:15, 6 May 2014
Background
- Meds
- Atropine
- Antihistamines
- Antidepressants (SSRIs, TCAs)
- Antipsychotics
- Muscle relaxants
- Plants
- Jimson weed (Devil's trumpet)
- Amanita mushroom
Clinical Features
- Dry as a bone: anhidrosis (esp axillae, mouth)
- Hot as a hare: anhydrotic hyperthermia (may become severe w/ agitation)
- Red as a beet: cutaneous vasodilation
- Blind as a bat: nonreactive mydriasis (often delayed 12-24hr)
- Mad as a hatter: delirium; attention deficit; hallucinations; dysarthria; lethargy
- Full as a flask: urinary retention
- Tachycardia (HR 120-160) and decreased/absent bowel sounds
DDX
- Sympathomimetic toxicity
- Red, dry skin and absent bowel sounds favors anticholinergic toxicity
- Encephalitis
- Head trauma
- ETOH/sedative withdrawal
- Neuroleptic Malignant Syndrome (NMS)
- Acute psychotic disorder
Toxidrome Differential Chart
Toxidrome Chart
| Finding | Cholinergic | Anticholinergic | Sympathomimetic | Sympatholytic^ | Sedative/Hypnotic |
| Example | Organophosphates | TCAs | Cocaine | Clonidine | ETOH |
| Temp | Nl | Nl / ↑ | Nl / ↑ | Nl / ↓ | Nl / ↓ |
| RR | Variable | Nl / ↓ | Variable | Nl / ↓ | Nl / ↓ |
| HR | Variable | ↑ | ↑ (sig) | Nl / ↓ | Nl / ↓ |
| BP | ↑ | ↑ | ↑ | Nl / ↓ | Nl / ↓ |
| LOC | Nl / Lethargic | Nl, agitated, psychotic, comatose | Nl, agitated, psychotic | Nl, Lethargic, or Comatose | Nl, Lethargic, or Comatose |
| Pupils | Variable | Mydriatic | Mydriatic | Nl / Miotic | |
| Motor | Fasciculations, Flacid Paralysis | Nl | Nl / Agitated | Nl | |
| Skin | Sweating (sig) | Hot, dry | Sweating | Dry | |
| Lungs | Bronchospasm / rhinorrhea | Nl | Nl | Nl | |
| Bowel Sounds | Hyperactive (SLUDGE) | ↓ / Absent | Nl / ↓ | Nl / ↓ |
- ^Consider Sympatholytic when looking at Sedative OD or someone who doesn't respond to Narcan
- Withdrawal from substances have the opposite effect
Treatment
- GI decon
- Activated Charcoal may be effective even >1hr after ingestion (decreased GI motility)
- Sedation
- Decreases the risk of hyperthermia, rhabdo, traumatic injuries
- Benzos are agents of choice
- Cholinesterase inhibition
- Indicated for severe agitation or delirium (esp if unresponsive to benzos)
- Avoid when cardiac conduction abnormalities are present
- Physostigmine
- Dosing: 0.5-2mg IV over 5min
- Onset of action: 15-20min
- Side effects: bradycardia, dysrhythmias, cholinergic excess
Disposition
- Consider d/c for pts w/ mild symptoms after 6hr obs if their symptoms resolve
- Admit if physostigmine was given (half-life of physo is often shorter than the ingested drug)
See Also
Source
Tintinalli