View source for Template:Anticholinergic Toxicity Treatement

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==Treatment== <!--T:1-->

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*Consider GI decon with [[Special:MyLanguage/Activated Charcoal|Activated Charcoal]] if patient presents <2 hours after ingestion and remains cooperative

===Sedation=== <!--T:3-->

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*Decreases the risk of [[Special:MyLanguage/hyperthermia|hyperthermia]], [[Special:MyLanguage/rhabdo|rhabdo]], traumatic injuries
*[[Special:MyLanguage/Benzos|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
**Goal: QRS duration < 110 msec

===Cholinesterase inhibition=== <!--T:5-->

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*Indicated for severe agitation or delirium (esp if unresponsive to [[Special:MyLanguage/benzos|benzos]])
*Contraindicated in QRS>100 or Na blockade signs (R' in aVR) and in narrow angle glaucoma
*Relatively contraindicated in asthma or ileus
*[[Special:MyLanguage/Physostigmine|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 [[Special:MyLanguage/atropine|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 [[Special:MyLanguage/TCA toxicity|TCA toxicity]] (associated with cardiac arrest) and in the presence of bradycardia or AV block

===Other therapies=== <!--T:7-->

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*[[Special:MyLanguage/Sodium bicarbonate|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
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