She was a 14 year-old rebellious, care-free, hippie, feminist, vegan, gluten-free teenager, sitting in her room watching Donald Trump’s RNC speech. It only took few minutes till she furiously got out her room and started roaming around the house. From afar, she saw her mommy’s orange pill box, typed on it with bold letters, size 18: Cyproheptadine 4mg every 6 hours as need. She took all 60 pills, and the last she heard was “I will make America great again” (Inspired by true events)
What are common clinical signs and symptoms in Anticholinergic toxicity? Tachycardia, absent/hypoactive bowel sounds, urinary retention, mydriasis, confusion, agitation, disorientation, and dry skin and mucous membranes. Anticholinergic toxidrome mnemonic: blind as a bat (mydriasis), mad as a hatter (altered mental status), red as a beet (vasodilation), hot as a hare (fever), dry as a bone, bowel and bladder lose their tone, heart runs alone (tachycardia) How can you clinically differentiate between sympathomimetic and anticholinergic toxidrome? In anticholinergic toxicity, skin is dry and bowel sounds are absent/hypoactive, while in sympathomimetic toxicity you have increased sweating (diaphoresis) and hyperactive bowel sounds. What are some common agents with anticholinergic properties? Tricyclic antidepressants, atropine, antihistamines (diphenhydramine, cyproheptadine, etc), Phenothiazine, and Jimson weed. What is the treatment of anticholinergic toxicity? Treatment is primarily supportive. The goal is to prevent life-threatening complications including status epilepticus, rhabdomyolysis, hyperthermia, and cardiovascular collapse. Benzodiazepines are the most commonly used drug. What is the anticholinergic antidote? When is it indicated? Physostigmine. It is indicated if conventional therapy fails to control seizures, agitation, unstable dysrhythmias, coma, or hypotension. Avoid if there is a known ingestion of cyclic antidepressants, QRS widening, seizures, or history of reactive airway disease. (Bonus Point: Physostigmine can be used as a diagnostic in small doses as well, meaning that if you have a patient that is altered without a clear cut history of ingestion, administering physostigmine and observing a response may make the diagnosis. Disclaimer: The political opinions expressed in this post are those of the author and do not necessarily reflect the official position of the blog and residency program. Reference: Tintinalli, Judith E., and David Cline. Tintinalli’s Emergency Medicine Manual. New York: McGraw-Hill Medical, 2012. Print. Special thanks to Dr. Willis
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