Template:Anticholinergic Toxicity Treatement: Difference between revisions
 
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==Treatment==
==Treatment==
#GI decon
*Consider GI decon with [[Activated Charcoal]] if patient presents <2 hours after ingestion and remains cooperative
#*[[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 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>
#*[[Benzos]] are agents of choice especially increase seizure threshold
**Repeat boluses every 5-15 minutes as needed to halt seizures and provide adequate sedation
#Conduction abnormalities (QRS prolongation)
**Goal: QRS duration < 110 msec
#*Sodium Bicarbonate
===Cholinesterase inhibition===
#**Should be given at 2 mEq/kg
*Indicated for severe agitation or delirium (esp if unresponsive to [[benzos]])
#**Typically 2-3 amps of bicarb
*Contraindicated in QRS>100 or Na blockade signs (R' in aVR) and in narrow angle glaucoma
#**Begin continuous NaCO3 infusions if bolus effective 
*Relatively contraindicated in asthma or ileus
#**Solution preparation = 1L D5W mixed with 3 ampules NaHCO3
*[[Physostigmine]] - strongly consider poison control consult before giving
#**Run NaHCO3 solutions at 250 mL/hr
**Crosses blood brain barrier, can be used to help make dx
#Cholinesterase inhibition
**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>
#*Indicated for severe agitation or delirium (esp if unresponsive to [[benzos]])
**Onset of action: 5-10min
#*Contraindicated in QRS>100 or Na blockade signs (R' in aVR)
**If partial response, repeat x3
#*Relative contraindicated in asthma or ileus
**If 3 or more administrations are needed over a 6-hour period, start IV infusion (bolus 1-2 mg followed by 1 mg/hour)
#*[[Physostigmine]]
**Stop infusion every 12 hours to determine resolution of the toxidrome
#**Crosses blood brain barrier, can be used to help make dx
**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>
#**Dosing: 0.5-2mg IV over 5min
**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>
#**Onset of action: 15-20min
**'''Contraindicated''' in [[TCA toxicity]] (associated with cardiac arrest) and in the presence of bradycardia or AV block
#**Side effects: bradycardia, dysrhythmias, cholinergic excess
===Other therapies===
#**Always have [[atropine]] at the bedside for bradycardia or cholinergic excess
*[[Sodium bicarbonate]] for conduction abnormalities (QRS prolongation)
#**'''Contraindicated''' in [[TCA toxicity]], associated with cardiac arrest
**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

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
  1. ↑ Burns MJ, et al. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med. 2000:35(4):374-381.
  2. ↑ Rosenbaum C and Bird SB. Timing and frequency for physostigmine redosing for antimuscarininc toxicity. J Med Toxicol. 2010;6:386-92.
  3. ↑ Pentel P and Peterson CD. Aystole complicating physostigmine treatment of tricyclic antidepressant overdose. Ann Emerg Med. 1980 Nov;9(11):588-90.
  4. ↑ Nguyen TT, et al. Adverse events from physostigmine: an observational study. Am J Emerg Med. 2018;36:141-2.
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