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‘Tis Saturday night and the adult ER is bustling with odors of aged urine and feet, zephyrs of fresh feces and half digested booze. A 33 year old man is placed in a dark corner; presumed intoxicated.
As you manage to wake him up, he admits to having a pack of Ili Pika’s who live in his eyeballs. They told him to drink all the pills in his bottle if he wants to meet them in space.
He hands you the pill bottle (after a good fundoscopic exam) and it says: Olanzapine.
On physical exam, he is somnolent and responding to external stimuli, dizzy when sitting up and asking for water for his dry mouth.
What is the toxidrome for this overdose? Atypical (second generation) antipsychotics: Antihistamine – 1 blockade: CNS depression. Alpha-1 blockade: Orthostatic hypotension, reflex tachycardia, dizziness, nasal congestion. Muscarinic – 1 blockade: Agitation, hallucinations, dry mucous membrane, urinary retention. Other known side effects may also be present: Extrapyramidal effects, Neuroleptic malignant syndrome, agranulocytosis. EKG most often shows sinus tachycardia with possible QTc prolongation (though Torsades has not been documented due to overdose). ~ Symptoms typically begin ~2 hours, peak ~4-6 hours and resolve ~12-48 hours. ~ People who are naive to the drug are more sensitive to the effects. ~ mortality is low.
What is your management: ABC, Monitor, IV access, EKG, POC glucose. Hypotension due to alpha 1 blockade: Fluids – > Pressors (alpha agonists) norepinephrine and phenylephrine. Avoid beta 2 blockade, it may cause more vasodilation. Dysrhythmias: ACLS. If need anti arrhythmic use Lidocaine. Avoid QTc prolonging agents (types IA, IC and III). Sodium bicarb for QRS prolongation. Recommended 1 dose of activated charcoal (if mental status permits). Cannot be dialyzed – protein bound, high volume of distribution (lipophilic). Dystonia: diphenhydramine, benztropine. NMS: Cooling. Benzodiazepines. Bromocriptine. Neuromuscular blockade.
A tiny bit more Physiology: All atypical antipsychotics have Dopamine receptor blockade (D2) in mesolimbic more than nigrostriatal region (therefore less extrapyramidal effects and more neurocognitive effects). They also have Serotonin, Alpha 1, Histamine 1 plus/minus muscarinic-1 blockade. Pharmacokinetics: These medications have a highly variable time to peak (1-10 hours), are lipophilic, protein bound and naturally accumulate in the brain. They are mostly cleared hepatically.
What is an Ili Pika you wonder?
References:
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