Template:Anticholinergic Toxicity Treatement: Difference between revisions
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==Treatment== | ==Treatment== | ||
*Consider GI decon with [[Activated Charcoal]] if patient presents <2 hours after ingestion and remains cooperative | *Consider GI decon with [[Activated Charcoal]] if patient presents <2 hours after ingestion and remains cooperative | ||
===Sedation=== | |||
*Decreases the risk of [[hyperthermia]], [[rhabdo]], traumatic injuries | |||
*[[Benzos]] are agents of choice especially increase seizure threshold<ref>Burns MJ, et al. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med. 2000:35(4):374-381.</ref> | |||
**Repeat boluses every 5-15 minutes as needed to halt seizures and provide adequate sedation | **Repeat boluses every 5-15 minutes as needed to halt seizures and provide adequate sedation | ||
**Goal: QRS duration < 110 msec | |||
===Cholinesterase inhibition=== | |||
*Indicated for severe agitation or delirium (esp if unresponsive to [[benzos]]) | |||
*Contraindicated in QRS>100 or Na blockade signs (R' in aVR) and in narrow angle glaucoma | |||
*Relatively contraindicated in asthma or ileus | |||
*[[Physostigmine]] - strongly consider poison control consult before giving | |||
**Crosses blood brain barrier, can be used to help make dx | |||
**Dosing: 0.5mg-1mg IV over 5min (repeat dosing up to 2mg in first hour)<ref>Rosenbaum C and Bird SB. Timing and frequency for physostigmine redosing for antimuscarininc toxicity. J Med Toxicol. 2010;6:386-92.</ref> | |||
**Onset of action: 5-10min | |||
**If partial response, repeat x3 | |||
**If 3 or more administrations are needed over a 6-hour period, start IV infusion (bolus 1-2 mg followed by 1 mg/hour) | |||
**Stop infusion every 12 hours to determine resolution of the toxidrome | |||
**Side effects: bradycardia, dysrhythmias, cholinergic excess<ref>Pentel P and Peterson CD. Aystole complicating physostigmine treatment of tricyclic antidepressant overdose. Ann Emerg Med. 1980 Nov;9(11):588-90.</ref> | |||
**Always have [[atropine]] at the bedside for bradycardia or cholinergic excess</ref><ref>Nguyen TT, et al. Adverse events from physostigmine: an observational study. Am J Emerg Med. 2018;36:141-2.</ref> | |||
**'''Contraindicated''' in [[TCA toxicity]] (associated with cardiac arrest) and in the presence of bradycardia or AV block | |||
===Other therapies=== | |||
*[[Sodium bicarbonate]] for conduction abnormalities (QRS prolongation) | *[[Sodium bicarbonate]] for conduction abnormalities (QRS prolongation) | ||
**2 mEq/kg bolus (typically 2-3 amps of bicarb) | **2 mEq/kg bolus (typically 2-3 amps of bicarb) | ||
**Begin continuous NaCO3 infusion at 250mL/hr if bolus effective | **Begin continuous NaCO3 infusion at 250mL/hr if bolus effective | ||
**Solution preparation = 1L D5W mixed with 3 ampules NaHCO3 | **Solution preparation = 1L D5W mixed with 3 ampules NaHCO3 | ||
Latest revision as of 21:19, 2 October 2020
Treatment
- Consider GI decon with Activated Charcoal if patient presents <2 hours after ingestion and remains cooperative
Sedation
- Decreases the risk of hyperthermia, rhabdo, traumatic injuries
- Benzos are agents of choice especially increase seizure threshold[1]
- Repeat boluses every 5-15 minutes as needed to halt seizures and provide adequate sedation
- Goal: QRS duration < 110 msec
Cholinesterase inhibition
- Indicated for severe agitation or delirium (esp if unresponsive to benzos)
- Contraindicated in QRS>100 or Na blockade signs (R' in aVR) and in narrow angle glaucoma
- Relatively contraindicated in asthma or ileus
- Physostigmine - strongly consider poison control consult before giving
- Crosses blood brain barrier, can be used to help make dx
- Dosing: 0.5mg-1mg IV over 5min (repeat dosing up to 2mg in first hour)[2]
- Onset of action: 5-10min
- If partial response, repeat x3
- If 3 or more administrations are needed over a 6-hour period, start IV infusion (bolus 1-2 mg followed by 1 mg/hour)
- Stop infusion every 12 hours to determine resolution of the toxidrome
- Side effects: bradycardia, dysrhythmias, cholinergic excess[3]
- Always have atropine at the bedside for bradycardia or cholinergic excess</ref>[4]
- Contraindicated in TCA toxicity (associated with cardiac arrest) and in the presence of bradycardia or AV block
Other therapies
- Sodium bicarbonate for conduction abnormalities (QRS prolongation)
- 2 mEq/kg bolus (typically 2-3 amps of bicarb)
- Begin continuous NaCO3 infusion at 250mL/hr if bolus effective
- Solution preparation = 1L D5W mixed with 3 ampules NaHCO3
- ↑ Burns MJ, et al. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med. 2000:35(4):374-381.
- ↑ Rosenbaum C and Bird SB. Timing and frequency for physostigmine redosing for antimuscarininc toxicity. J Med Toxicol. 2010;6:386-92.
- ↑ Pentel P and Peterson CD. Aystole complicating physostigmine treatment of tricyclic antidepressant overdose. Ann Emerg Med. 1980 Nov;9(11):588-90.
- ↑ Nguyen TT, et al. Adverse events from physostigmine: an observational study. Am J Emerg Med. 2018;36:141-2.