{ "schemaVersion": 2, "eyebrow": "Medical Toxicology", "title": "Anticholinergic Toxicity", "summary": "Recognize the clinical antimuscarinic pattern, identify sodium-channel blockade or competing toxidromes, stabilize hyperthermia and agitation, and select physostigmine only for consequential delirium after electrocardiographic risk assessment.", "seoDescription": "Point-of-care approach to anticholinergic toxicity: diagnosis, ECG assessment, stabilization, physostigmine selection, and exposure-specific management.", "clinicalQuestion": "How should clinicians diagnose, stabilize, and selectively reverse acute anticholinergic toxicity?", "specialty": "Emergency Medicine and Medical Toxicology", "audience": "U.S. physicians and medical trainees", "tags": [ "anticholinergic toxidrome", "antimuscarinic delirium", "physostigmine", "tricyclic antidepressant overdose", "Datura poisoning", "drug-induced urinary retention" ], "keyTakeaways": [ "Diagnose anticholinergic toxicity clinically from delirium plus peripheral muscarinic blockade; dry skin and mucous membranes, mydriasis, tachycardia, reduced bowel sounds, and urinary retention support the diagnosis. [1][6][21]", "Obtain a fingerstick glucose and 12-lead ECG early; QRS duration greater than 100 ms or wide-complex tachycardia directs management toward sodium bicarbonate and raises concern for tricyclic antidepressant sodium-channel blockade. [6][8]", "Use physostigmine selectively for consequential antimuscarinic delirium after ECG assessment; avoid its use in patients at very high risk of adverse effects and do not use it as a substitute for managing conduction disturbance. [6][12]", "Treat acute urinary retention with bladder catheterization and stop or reduce the causal drug when feasible; older adults and patients with benign prostatic hyperplasia have greater vulnerability. [24]", "Clustered illness after shared food, tea, or illicit-drug use should trigger an exposure investigation for plant alkaloids or adulterants such as Datura, belladonna, or scopolamine. [13][20][21][22]" ], "sections": [ { "id": "first-hour-triage", "eyebrow": "Immediate Care", "heading": "First-hour priorities in suspected anticholinergic poisoning", "intro": "Treat physiologic threats while determining whether the presentation is a pure antimuscarinic syndrome or a mixed overdose.", "paragraphs": [ "Perform immediate airway, ventilation, circulation, temperature, mental-status, and point-of-care glucose assessment. Escalating agitation, coma, seizures, hyperthermia, or unstable tachyarrhythmia should be managed as severe poisoning rather than attributed solely to delirium. Anticholinergic toxicity may produce agitation, psychosis, perceptual distortion, hyperthermia, tachycardia, urinary retention, and ileus. [1][6][14]", "Place the patient on cardiac monitoring and obtain a 12-lead ECG early. In suspected tricyclic antidepressant (TCA) poisoning, clinical deterioration may occur within 1 to 2 hours; sinus tachycardia may progress to wide-complex tachycardia and ventricular arrhythmias. [2] A QRS duration greater than 100 ms or a rightward shift of the terminal 40-ms frontal-plane QRS vector identifies patients at greater risk for cardiac or neurologic toxicity, although ECG findings alone neither confirm nor exclude impending severe toxicity. [8]", "Obtain a focused exposure history from family, emergency medical services, pharmacy records, and packaging: sedating antihistamines, antidepressants, antipsychotics, sleep aids, muscle relaxants, inhaled anticholinergics, and plant products are important medication branches. Diphenhydramine, chlorpheniramine, psychiatric medications, and jimsonweed are recognized causes. [1][6] A shared tea, meal, or street-drug exposure with simultaneous presentations should prompt notification of poison-center and public-health partners because Datura and scopolamine adulteration have produced clusters of severe illness. [20][21][22]" ], "bullets": [ "Use bedside glucose to exclude hypoglycemia as a reversible contributor to altered mental status. [6]", "Repeat clinical and ECG assessment if mental status or rhythm worsens; early ECG abnormalities are common among TCA-poisoned patients at significant risk. [8]", "Catheterize acute urinary retention rather than allowing persistent bladder distension; then discontinue or reduce the offending drug when clinically feasible. [24]" ], "subsections": [], "table": { "caption": "Initial branch points in a patient with suspected anticholinergic toxicity. [1][6][8][24]", "columns": [ "Finding", "Interpretation", "Immediate action" ], "rows": [ [ "Dry skin or mucosa, mydriasis, tachycardia, reduced bowel sounds, urinary retention, delirium", "Clinical antimuscarinic pattern; absence of sweating is a particularly useful examination finding. [1][6]", "Cardiac monitoring, glucose, ECG, exposure history, and management of agitation, hyperthermia, or retention. [6][24]" ], [ "QRS >100 ms, wide-complex tachycardia, or terminal 40-ms rightward axis shift", "Suggests clinically important sodium-channel blockade, particularly with TCA exposure. [6][8]", "Give sodium bicarbonate for QRS >100 ms or wide-complex tachycardia; do not treat the ECG abnormality as uncomplicated antimuscarinic delirium. [6]" ], [ "Bradycardia, diaphoresis, miosis, bronchial secretions, or diarrhea", "Findings argue against a pure antimuscarinic syndrome and require reassessment for an alternate or mixed toxidrome. [1]", "Reframe the differential and avoid reflexive antidote use based on delirium alone. [1][12]" ] ] } }, { "id": "clinical-diagnosis-and-differential", "eyebrow": "Diagnosis", "heading": "Make the diagnosis clinically and identify dangerous mimics", "intro": "No routine laboratory assay confirms anticholinergic toxicity.", "paragraphs": [ "Anticholinergic poisoning is a clinical diagnosis based on compatible exposure plus central and peripheral findings; routine clinical laboratory testing does not detect the syndrome. [21] Delirium with dry skin and mucosa, flushing, nonreactive mydriasis, tachycardia, hypoactive or absent bowel sounds, and urinary retention is more discriminating than altered mental status alone. [1][20][21][22]", "Separate antimuscarinic delirium from sympathomimetic toxicity at the bedside by assessing sweating and mucosal moisture. Both syndromes can cause tachycardia, mydriasis, hyperthermia, agitation, and hypertension, but antimuscarinic poisoning is characteristically dry, whereas sympathomimetic poisoning is typically associated with diaphoresis. The absence of sweating is a key physical finding supporting anticholinergic syndrome. [1][6]", "Do not assume that a recognizable anticholinergic examination excludes TCA cardiotoxicity. TCAs combine antimuscarinic effects with sodium-channel blockade; toxidrome findings alone are insufficient to detect or exclude clinically important TCA toxicity. [6][8] The ECG therefore changes both disposition and antidote selection when a cyclic antidepressant or another sodium-channel blocker is plausible." ], "bullets": [ "Examine for bladder distension and obtain a bladder assessment when retention is suspected; acute retention warrants catheterization. [24]", "Ask specifically about herbal tea, homemade foods, foraged plants, and seeds or leaves. Datura contains atropine, hyoscyamine, and scopolamine; symptoms have begun from 5 minutes to 3 hours after ingestion in reported cases. [13]", "In illicit-drug users with unexpected delirium after opioid exposure, consider adulteration with scopolamine; naloxone may unmask or worsen agitation and hallucinations without reversing the antimuscarinic syndrome. [22]" ], "subsections": [ { "heading": "Exposure patterns that change the next step", "paragraphs": [ "A household cluster after tea or food is a high-yield clue to plant poisoning. Reported Datura and jimsonweed outbreaks produced mydriasis, tachycardia, dry mucosa or skin, hallucinations, confusion, and variable severity among co-exposed persons. [13][20][21] Identify and preserve the remaining food, tea, plant, or drug material when feasible for public-health or toxicology evaluation." ], "bullets": [ "Datura or jimsonweed: consider after intentional plant use, foraging, herbal preparations, or shared meals. [13][21]", "Belladonna: consider after ingestion of raw leaves or other plant parts with delirium, dry mouth, mydriasis, and tachycardia. [14]", "Adulterated heroin: consider when an apparent opioid exposure evolves into dry delirium, mydriasis, and ileus, especially among multiple patients. [22]" ] } ], "table": { "caption": "Clinical discriminators for anticholinergic toxicity and important competing patterns. [1][6][8][22]", "columns": [ "Pattern", "Discriminating findings", "Management implication" ], "rows": [ [ "Predominantly antimuscarinic toxicity", "Dry skin and mucosa, flushing, mydriasis, tachycardia, ileus, urinary retention, and delirium. [1][6]", "Support vital functions; evaluate ECG before considering physostigmine for consequential delirium. [6][12]" ], [ "TCA or other sodium-channel blocker co-toxicity", "Anticholinergic findings plus QRS >100 ms, wide-complex tachycardia, or terminal 40-ms rightward axis shift. [6][8]", "Treat conduction toxicity with sodium bicarbonate; do not rely on the toxidrome alone. [6][8]" ], [ "Sympathomimetic toxicity", "Agitation, tachycardia, hypertension, hyperthermia, and mydriasis can overlap, but sweating favors this pattern over antimuscarinic poisoning. [1][6]", "Reassess the exposure and avoid diagnosing anticholinergic syndrome on pupil size and tachycardia alone. [1]" ], [ "Opioid exposure with scopolamine adulteration", "Naloxone may increase agitation and hallucinations; dry skin, dilated pupils, reduced bowel sounds, and retention support scopolamine toxicity. [22]", "Manage the antimuscarinic syndrome after addressing opioid-related respiratory depression. [22]" ] ] } }, { "id": "supportive-management", "eyebrow": "Stabilization", "heading": "Treat agitation, hyperthermia, conduction toxicity, and retention", "intro": "Management is driven by the complication present, not by a single antidote decision.", "paragraphs": [ "Use supportive treatment as the baseline strategy because most anticholinergic poisonings have a favorable outcome with vital-sign support and observation. [6] For agitation, benzodiazepines are part of basic treatment; they are particularly appropriate while the diagnosis remains uncertain, when seizures are present, or when physostigmine is not appropriate. [6]", "Treat hyperthermia actively and reassess for severe central toxicity. Hyperthermia is a recognized feature of antimuscarinic poisoning, and central involvement with agitation, hallucinations, delirium, seizures, loss of consciousness, or coma signals greater severity. [1][14] Patients with predominant severe central manifestations may require intensive hemodynamic monitoring. [14]", "For QRS duration greater than 100 ms or wide-complex tachycardia, administer sodium bicarbonate rather than treating this as uncomplicated antimuscarinic delirium. [6] This ECG branch is especially important after suspected TCA ingestion because sodium-channel blockade, rather than muscarinic antagonism, drives the major conduction abnormalities. [8]", "Address urinary retention directly. Acute drug-induced retention is generally managed with bladder catheterization plus discontinuation or dose reduction of the causal medication. [24] Anticholinergic medications, antipsychotics, antidepressants, inhaled anticholinergics, opioids, benzodiazepines, alpha-agonists, NSAIDs, calcium-channel blockers, and anesthetics can contribute; older adults are at increased risk because of comorbidity, including benign prostatic hyperplasia, and additive medication effects. [24]" ], "bullets": [ "Benzodiazepines: use for agitation as part of initial symptomatic management. [6]", "Sodium bicarbonate: use for QRS >100 ms or wide-complex tachycardia. [6]", "Bladder catheterization: use for acute urinary retention, with medication reconciliation to remove additive contributors. [24]", "Intensive monitoring: consider when severe central manifestations predominate, including severe delirium, seizures, loss of consciousness, or marked agitation. [14]" ], "subsections": [], "table": { "caption": "Complication-directed management in anticholinergic toxicity. [6][14][24]", "columns": [ "Complication", "Action", "Key limitation or escalation point" ], "rows": [ [ "Agitated delirium", "Use benzodiazepines for symptomatic agitation; assess whether physostigmine is appropriate after ECG review. [6][12]", "Do not use antidote therapy before considering TCA-associated conduction toxicity. [6][8]" ], [ "QRS >100 ms or wide-complex tachycardia", "Administer sodium bicarbonate. [6]", "Treat as sodium-channel blockade; antimuscarinic signs do not exclude this branch. [8]" ], [ "Hyperthermia or severe neurologic toxicity", "Provide active supportive management and close hemodynamic monitoring when central manifestations predominate. [1][14]", "Escalate care for seizures, loss of consciousness, coma, or worsening instability. [14]" ], [ "Acute urinary retention", "Perform bladder catheterization and stop or reduce the causal drug when feasible. [24]", "Review for benign prostatic hyperplasia and additive retention-promoting medications. [24]" ] ] } }, { "id": "physostigmine-selection", "eyebrow": "Antidote", "heading": "When physostigmine is appropriate—and when ECG findings change the plan", "intro": "Reserve physostigmine for clinically consequential central and peripheral antimuscarinic manifestations after risk stratification.", "paragraphs": [ "Physostigmine is a centrally acting acetylcholinesterase inhibitor that reverses both central and peripheral antimuscarinic effects by increasing synaptic acetylcholine. [1][7] It is an effective, relatively safe treatment for anticholinergic delirium, but use should be selective rather than automatic because safety concerns, optimal dosing, and patient selection remain clinically important. [12][18]", "Consider physostigmine when a patient has an otherwise convincing antimuscarinic syndrome with consequential agitated delirium and no ECG conduction disturbance. [6] The principal pre-administration decision is whether the patient could have sodium-channel blockade, particularly TCA toxicity: QRS prolongation or wide-complex rhythm should redirect treatment to sodium bicarbonate and supportive resuscitation. [6][8]", "Avoid physostigmine in patients at very high risk of adverse effects. [12] Historical concern has focused on cyclic antidepressant ingestion and QRS prolongation; some reviews question whether every possible cyclic-antidepressant exposure or every ECG criterion should be an absolute contraindication. [7] In practice, the safer operational distinction is between a clear, ECG-normal, predominantly antimuscarinic delirium and a possible mixed overdose with conduction abnormality, where the competing cardiotoxicity must take priority. [6][8][12]", "Physostigmine can produce rapid reversal in observed outbreaks and case series, but its duration may be shorter than the poisoning syndrome. [20][17] Reassess mental status, pulse, blood pressure, and ECG after reversal; recurrent delirium requires renewed evaluation for ongoing absorption, co-ingestion, or a longer-acting agent rather than assuming diagnostic closure." ], "bullets": [ "Favors physostigmine: consequential delirium with a convincing antimuscarinic examination and no conduction disturbance on ECG. [6][12]", "Favors benzodiazepines and supportive care: uncertain toxidrome, mixed ingestion, seizure, or high-risk antidote profile. [6][12]", "Favors sodium bicarbonate: QRS >100 ms or wide-complex tachycardia. [6]", "Do not interpret improvement after physostigmine as proof that no co-ingestion occurred; ECG and serial clinical reassessment remain necessary. [8][12]" ], "subsections": [ { "heading": "Dose reporting and monitoring", "paragraphs": [ "Published outbreak reports describe intravenous physostigmine administered over 5 minutes, including 0.5-mg doses in a child and 2-mg doses in adults, with complete resolution of manifestations in those reports. [20] These observations support slow intravenous administration with monitoring but do not establish a universal dose regimen across adults, children, agents, or mixed overdoses." ], "bullets": [ "Use continuous cardiac monitoring and ECG-based selection when administering physostigmine for delirium. [6][8][12]", "If delirium recurs after initial response, reassess the exposure and ongoing toxicity; longer-duration cholinesterase inhibition with rivastigmine has been described after severe anticholinergic delirium. [17]" ] } ], "table": { "caption": "Physostigmine decision framework for antimuscarinic delirium. [6][7][8][12][20]", "columns": [ "Clinical state", "Physostigmine role", "Required next action" ], "rows": [ [ "Consequential agitated delirium with convincing antimuscarinic findings and no ECG conduction disturbance", "Reasonable antidotal option for central and peripheral manifestations. [6][7][12]", "Use monitored administration and reassess mental status and ECG after reversal. [6][8]" ], [ "QRS >100 ms or wide-complex tachycardia", "Do not prioritize physostigmine for this presentation. [6][8]", "Administer sodium bicarbonate and manage sodium-channel blockade. [6]" ], [ "Possible TCA or other mixed overdose without diagnostic clarity", "Risk-benefit is unfavorable until cardiotoxicity is assessed. [7][8][12]", "Obtain and interpret ECG; provide supportive care and benzodiazepines for agitation. [6][8]" ], [ "Recurrent delirium after reversal", "Repeat treatment decisions require renewed risk assessment; duration mismatch can occur. [17][20]", "Reassess exposure, ECG, and level of monitoring; consider toxicology consultation. [8][17]" ] ] } }, { "id": "disposition-and-prevention", "eyebrow": "Disposition", "heading": "Monitor for evolving cardiotoxicity and prevent recurrence", "intro": "Disposition depends on trajectory, ECG findings, severity of central toxicity, and whether exposure is isolated or ongoing.", "paragraphs": [ "Continue observation with serial clinical and ECG assessment when TCA exposure is possible because significant cardiovascular and neurologic deterioration can occur early and ECG abnormalities may emerge during emergency-department evaluation. [2][8] ICU-level monitoring is appropriate for patients with severe central manifestations or hemodynamic instability. [14]", "Before discharge after a medication-related event, reconcile all agents that impair bladder emptying or add anticholinergic burden. Acute urinary retention is associated with antipsychotics, antidepressants, anticholinergic respiratory medications, opioids, benzodiazepines, alpha-agonists, NSAIDs, detrusor relaxants, calcium-channel blockers, and anesthetics; medication combinations can amplify risk. [24]", "For plant, food, tea, or illicit-drug clusters, document the suspected source and alert poison-center and public-health channels. Datura-related outbreaks have followed herbal tea and homemade food, while scopolamine-adulterated heroin has produced regional clusters; recognition protects co-exposed persons who may still be symptomatic or deteriorate. [20][21][22]" ], "bullets": [ "Do not use an initially reassuring toxidrome examination to rule out TCA-related cardiotoxicity; use serial ECG and clinical trajectory. [8]", "Treat severe central toxicity as a monitoring indication even when the plant or medication exposure is known. [14]", "Review retention risk before restarting or adding anticholinergic medications, especially in older adults and those with benign prostatic hyperplasia. [24]" ], "subsections": [], "table": { "caption": "Disposition triggers after suspected anticholinergic poisoning. [2][8][14][24]", "columns": [ "Finding during evaluation", "Disposition implication", "Monitoring focus" ], "rows": [ [ "Severe delirium, seizures, loss of consciousness, or marked agitation", "Use close hemodynamic monitoring; ICU-level care may be appropriate. [14]", "Mental status, temperature, cardiorespiratory status, and recurrent toxicity. [14]" ], [ "TCA exposure possible or ECG conduction abnormality", "Continue monitored observation for evolving cardiovascular and neurologic toxicity. [2][8]", "Serial ECG and rhythm assessment. [8]" ], [ "Acute urinary retention", "Do not discharge without catheter management and medication review. [24]", "Return of bladder emptying and removal or reduction of causal medications. [24]" ], [ "Multiple people ill after shared exposure", "Identify and evaluate co-exposed persons and notify relevant public-health resources. [20][21][22]", "Exposure source and delayed or variable clinical presentations. [21]" ] ] } } ], "faq": [], "references": [ { "number": 1, "title": "Toxidromes and a general approach to poisoning", "detail": "adc.bmj.com", "url": "https://adc.bmj.com/content/110/9/681", "authors": "adc.bmj.com", "host": "adc.bmj.com" }, { "number": 2, "title": "Tricyclic antidepressant overdose - Symptoms, diagnosis and treatment | BMJ Best Practice US", "detail": "bestpractice.bmj.com", "url": "https://bestpractice.bmj.com/topics/en-us/342", "authors": "bestpractice.bmj.com", "host": "bestpractice.bmj.com" }, { "number": 3, "title": "Cocaine toxicity - Symptoms, diagnosis and treatment | BMJ Best Practice US", "detail": "bestpractice.bmj.com", "url": "https://bestpractice.bmj.com/topics/en-us/340", "authors": "bestpractice.bmj.com", "host": "bestpractice.bmj.com" }, { "number": 4, "title": "Treatment of pediatric antimuscarinic delirium with oral rivastigmine", "detail": "academic.oup.com", "url": "https://academic.oup.com/omcr/article-pdf/2023/9/omad096/51752251/omad096.pdf", "authors": "academic.oup.com", "host": "academic.oup.com" }, { "number": 5, "title": "Anticholinergic toxidrome in a toddler with unwitnessed ingestion ...", "detail": "academic.oup.com", "url": "https://academic.oup.com/jat/advance-article-pdf/doi/10.1093/jat/bkag066/68969296/bkag066.pdf", "authors": "academic.oup.com", "host": "academic.oup.com" }, { "number": 6, "title": "Anticholinergic Syndrome - an overview", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/topics/medicine-and-dentistry/anticholinergic-syndrome", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 7, "title": "Physostigmine treatment of anticholinergic poisoning - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/pii/S036111247680192X", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 8, "title": "ECG abnormalities in tricyclic antidepressant ingestion", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0735675799900943", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 9, "title": "DELIRIUM - Continuum - American Academy of Neurology", "detail": "journals.lww.com", "url": "https://journals.lww.com/continuum/fulltext/2010/04000/delirium.10.aspx", "authors": "journals.lww.com", "host": "journals.lww.com" }, { "number": 10, "title": "Prevalence of autonomic signs and symptoms in antimuscarinic drug poisonings - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0736467903002956", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com" }, { "number": 11, "title": "Physostigmine should be used more readily for antimuscarinic ...", "detail": "bpspubs.onlinelibrary.wiley.com", "url": "https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.15120", "authors": "bpspubs.onlinelibrary.wiley.com", "host": "bpspubs.onlinelibrary.wiley.com" }, { "number": 12, "title": "Pharmacological management of anticholinergic delirium", "detail": "bpspubs.onlinelibrary.wiley.com", "url": "https://bpspubs.onlinelibrary.wiley.com/doi/pdf/10.1111/bcp.12839", "authors": "bpspubs.onlinelibrary.wiley.com", "host": "bpspubs.onlinelibrary.wiley.com" }, { "number": 13, "title": "Datura poisoning in a family: Case series and literature review - Khoshnam‐Rad - 2022 - Clinical Case Reports - Wiley Online Library", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.6091", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 14, "title": "Severe Neurotoxicity due to Atropa belladonna Poisoning: A Case Report and Literature Review - Boskabadi - 2024 - Case Reports in Neurological Medicine - Wiley Online Library", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/abs/10.1155/2024/5411258", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 15, "title": "Case series: Acute management of prescription and nonprescription ...", "detail": "accpjournals.onlinelibrary.wiley.com", "url": "https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/jac5.1931", "authors": "accpjournals.onlinelibrary.wiley.com", "host": "accpjournals.onlinelibrary.wiley.com" }, { "number": 16, "title": "The Role of Dexmedetomidine in Pediatric Patients Presenting with ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1155/2021/7590960", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 17, "title": "Case series profile of olanzapine post‐injection delirium/sedation ...", "detail": "bpspubs.onlinelibrary.wiley.com", "url": "https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111%2Fbcp.15588", "authors": "bpspubs.onlinelibrary.wiley.com", "host": "bpspubs.onlinelibrary.wiley.com" }, { "number": 18, "title": "Pharmacological management of anticholinergic delirium ‐ theory ...", "detail": "bpspubs.onlinelibrary.wiley.com", "url": "https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.12839", "authors": "bpspubs.onlinelibrary.wiley.com", "host": "bpspubs.onlinelibrary.wiley.com" }, { "number": 19, "title": "[PDF] COMIRB Protocol - ClinicalTrials.gov", "detail": "cdn.clinicaltrials.gov", "url": "https://cdn.clinicaltrials.gov/large-docs/20/NCT03090620/Prot_SAP_000.pdf", "authors": "cdn.clinicaltrials.gov", "host": "cdn.clinicaltrials.gov" }, { "number": 20, "title": "Anticholinergic Poisoning Associated\r\nwith an Herbal Tea -- New York City, 1994", "detail": "www.cdc.gov", "url": "https://www.cdc.gov/mmwr/preview/mmwrhtml/00036554.htm", "authors": "www.cdc.gov", "host": "www.cdc.gov" }, { "number": 21, "title": "Jimsonweed Poisoning Associated with a Homemade Stew --- Maryland, 2008", "detail": "www.cdc.gov", "url": "https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5904a3.htm", "authors": "www.cdc.gov", "host": "www.cdc.gov" }, { "number": 22, "title": "Scopolamine Poisoning among Heroin Users -- New York City,\r\nNewark, Philadelphia, and Baltimore, 1995 and 1996", "detail": "www.cdc.gov", "url": "https://www.cdc.gov/mmwr/preview/mmwrhtml/00042596.htm", "authors": "www.cdc.gov", "host": "www.cdc.gov" }, { "number": 23, "title": "CDC Clinical Practice Guideline for Prescribing Opioids for Pain", "detail": "www.cdc.gov", "url": "https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm", "authors": "www.cdc.gov", "host": "www.cdc.gov" }, { "number": 24, "title": "Drug-induced urinary retention: incidence, management and prevention - PubMed", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/lookup/external-ref?access_num=18422378&link_type=MED&atom=%2Fccjom%2F91%2F12%2F762.atom", "authors": "www.ccjm.org", "host": "www.ccjm.org" } ], "editorialNote": "Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.", "citations": [ { "number": 1, "title": "Toxidromes and a general approach to poisoning", "detail": "adc.bmj.com", "url": "https://adc.bmj.com/content/110/9/681", "authors": "adc.bmj.com", "host": "adc.bmj.com", "snippet": "### Anticholinergic toxidrome\n\nThe anticholinergic toxidrome mnemonic is ‘red as a beet, dry as a bone, blind as a bat, mad as a hatter, and full as a flask’. Causal medications include antihistamines such as diphenhydramine and chlorpheniramine, numerous psychiatric medications including antidepres", "score": 0.45028743 }, { "number": 2, "title": "Tricyclic antidepressant overdose - Symptoms, diagnosis and treatment | BMJ Best Practice US", "detail": "bestpractice.bmj.com", "url": "https://bestpractice.bmj.com/topics/en-us/342", "authors": "bestpractice.bmj.com", "host": "bestpractice.bmj.com", "snippet": "##### Peer reviewer acknowledgements\n\nBMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.\n\n###### Disclosures\n\nPeer reviewer affiliations an", "score": 0.38532895 }, { "number": 3, "title": "Cocaine toxicity - Symptoms, diagnosis and treatment | BMJ Best Practice US", "detail": "bestpractice.bmj.com", "url": "https://bestpractice.bmj.com/topics/en-us/340", "authors": "bestpractice.bmj.com", "host": "bestpractice.bmj.com", "snippet": "###### Disclosures\n\nPeer reviewer affiliations and disclosures pertain to the time of the review.\n\n### References\n\n#### Key articles\n\nLavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicit", "score": 0.1391976 }, { "number": 4, "title": "Treatment of pediatric antimuscarinic delirium with oral rivastigmine", "detail": "academic.oup.com", "url": "https://academic.oup.com/omcr/article-pdf/2023/9/omad096/51752251/omad096.pdf", "authors": "academic.oup.com", "host": "academic.oup.com", "snippet": "Antimuscarinic drug toxicity is a common pediatric emergency, The 'anticholinergic' or antimuscarinic toxidrome, Central symptoms include agitation, delirium,", "score": 0.47022632 }, { "number": 5, "title": "Anticholinergic toxidrome in a toddler with unwitnessed ingestion ...", "detail": "academic.oup.com", "url": "https://academic.oup.com/jat/advance-article-pdf/doi/10.1093/jat/bkag066/68969296/bkag066.pdf", "authors": "academic.oup.com", "host": "academic.oup.com", "snippet": "The 37th Annual Meeting of Japanese Society of Emergency Pediatrics. The 9th Annual Meeting of the Japanese Society of Clinical and Analytical Toxicology.", "score": 0.24136461 }, { "number": 6, "title": "Anticholinergic Syndrome - an overview", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/topics/medicine-and-dentistry/anticholinergic-syndrome", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "•\nThe diagnosis of anticholinergic syndrome is largely clinical and should include physical examination, fingerstick serum glucose measurement, and an electrocardiogram.\n\n•\nAnticholinergic syndrome is a key clinical finding leading to the diagnosis of poisoning by tricyclic antidepressants (a subset", "score": 0.5550741 }, { "number": 7, "title": "Physostigmine treatment of anticholinergic poisoning - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/pii/S036111247680192X", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "# Emergency Case Report Physostigmine treatment of anticholinergic poisoning. Physostigmine salicylate, a centrally acting cholinesterase inhibitor, is effective in rapidly and dramatically reversing the effects produced by anticholinergic drugs. Since physostigmine is a tertiary amine that allows f", "score": 0.5101799 }, { "number": 8, "title": "ECG abnormalities in tricyclic antidepressant ingestion", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0735675799900943", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "The tricyclic antidepressant (TCA) agents are recognized for their potentially lethal cardiovascular and neurological effects in poisoned patients. The 12-lead electrocardiogram (ECG) has emerged as a popular bedside tool in the evaluation of TCA toxicity. Although the history and physical examinati", "score": 0.27648583 }, { "number": 9, "title": "DELIRIUM - Continuum - American Academy of Neurology", "detail": "journals.lww.com", "url": "https://journals.lww.com/continuum/fulltext/2010/04000/delirium.10.aspx", "authors": "journals.lww.com", "host": "journals.lww.com", "snippet": "In some cases, delirium results from the direct effect of a toxin, as observed with anticholinergic medications, or from neuronal injury, as seen in herpes", "score": 0.26703572 }, { "number": 10, "title": "Prevalence of autonomic signs and symptoms in antimuscarinic drug poisonings - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0736467903002956", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "Elsevier logo\nThe Journal of Emergency Medicine\n\n## The Journal of Emergency Medicine\n\n## Published by: Elsevier\n\n### Published by\n\nElsevier\n\n# Selected topic: toxicology Prevalence of autonomic signs and symptoms in antimuscarinic drug poisonings\n\n## Article preview\n\n## Abstract\n\n## Keywords\n\n## In", "score": 0.2435709 }, { "number": 11, "title": "Physostigmine should be used more readily for antimuscarinic ...", "detail": "bpspubs.onlinelibrary.wiley.com", "url": "https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.15120", "authors": "bpspubs.onlinelibrary.wiley.com", "host": "bpspubs.onlinelibrary.wiley.com", "snippet": "Physostigmine is the preferred treatment for antimuscarinic toxicity. demonstrated effectiveness and safety. : a 10-year retrospective review.", "score": 0.7640656 }, { "number": 12, "title": "Pharmacological management of anticholinergic delirium", "detail": "bpspubs.onlinelibrary.wiley.com", "url": "https://bpspubs.onlinelibrary.wiley.com/doi/pdf/10.1111/bcp.12839", "authors": "bpspubs.onlinelibrary.wiley.com", "host": "bpspubs.onlinelibrary.wiley.com", "snippet": "Physostigmine is an effective and relatively safe agent to use in anticholinergic delirium. It should be avoided in those at very high risk of", "score": 0.6350646 }, { "number": 13, "title": "Datura poisoning in a family: Case series and literature review - Khoshnam‐Rad - 2022 - Clinical Case Reports - Wiley Online Library", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.6091", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "# Datura poisoning in a family: Case series and literature review. *Datura spp.* is a potentially poisonous plant that is widely spread and is simply accessible, which can yield poisoning with a central and peripheral anticholinergic effect. We reported cases of family poisoning caused by the herbal", "score": 0.62330866 }, { "number": 14, "title": "Severe Neurotoxicity due to Atropa belladonna Poisoning: A Case Report and Literature Review - Boskabadi - 2024 - Case Reports in Neurological Medicine - Wiley Online Library", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/abs/10.1155/2024/5411258", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "# Severe Neurotoxicity due to *Atropa belladonna* Poisoning: A Case Report and Literature Review. belladonna* poisoning resulting from accidental ingestion of the plant’s raw leaves, which were referred to the emergency room of a poisoning center in northern Iran. Both patients presented with sympto", "score": 0.5611433 }, { "number": 15, "title": "Case series: Acute management of prescription and nonprescription ...", "detail": "accpjournals.onlinelibrary.wiley.com", "url": "https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/jac5.1931", "authors": "accpjournals.onlinelibrary.wiley.com", "host": "accpjournals.onlinelibrary.wiley.com", "snippet": "Since the time of these cases being published, numerous data sets have emerged supporting the safety of physostigmine in anticholinergic", "score": 0.560566 }, { "number": 16, "title": "The Role of Dexmedetomidine in Pediatric Patients Presenting with ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1155/2021/7590960", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "While recent articles argue that physostigmine is a safe and effective treatment of pure anticholinergic toxidrome [4], clinical use remains", "score": 0.53269315 }, { "number": 17, "title": "Case series profile of olanzapine post‐injection delirium/sedation ...", "detail": "bpspubs.onlinelibrary.wiley.com", "url": "https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111%2Fbcp.15588", "authors": "bpspubs.onlinelibrary.wiley.com", "host": "bpspubs.onlinelibrary.wiley.com", "snippet": "Patients who develop severe anticholinergic delirium can be managed with physostigmine followed by rivastigmine, which has longer duration of", "score": 0.43266314 }, { "number": 18, "title": "Pharmacological management of anticholinergic delirium ‐ theory ...", "detail": "bpspubs.onlinelibrary.wiley.com", "url": "https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.12839", "authors": "bpspubs.onlinelibrary.wiley.com", "host": "bpspubs.onlinelibrary.wiley.com", "snippet": "Cholinesterase inhibitors, such as physostigmine, are effective but widespread use has been limited by concerns about safety, optimal dosing and", "score": 0.4280666 }, { "number": 19, "title": "[PDF] COMIRB Protocol - ClinicalTrials.gov", "detail": "cdn.clinicaltrials.gov", "url": "https://cdn.clinicaltrials.gov/large-docs/20/NCT03090620/Prot_SAP_000.pdf", "authors": "cdn.clinicaltrials.gov", "host": "cdn.clinicaltrials.gov", "snippet": "for severe CNS anticholinergic toxicity. Emerg Med J. 2001 Sep;18(5):412. 12. Beaver KM, Gavin TJ. Treatment of acute anticholinergic poisoning with physostigmine. Am J Emerg Med. 1998 Sep;16(5):505-7. 13. Arnold SM, Arnholz D, Garyfallou GT, Heard K. Two siblings poisoned with diphenhydramine: a ca", "score": 0.5928793 }, { "number": 20, "title": "Anticholinergic Poisoning Associated\r\nwith an Herbal Tea -- New York City, 1994", "detail": "www.cdc.gov", "url": "https://www.cdc.gov/mmwr/preview/mmwrhtml/00036554.htm", "authors": "www.cdc.gov", "host": "www.cdc.gov", "snippet": "On March 23, four family members shared a pot of tea.\nApproximately 1 hour later, the 10-year-old son was transported by\nhis parents to a local emergency department because of agitation\nand restlessness. Findings on examination included increased pulse\n(120 beats per minute), dilated and nonreactive", "score": 0.50388235 }, { "number": 21, "title": "Jimsonweed Poisoning Associated with a Homemade Stew --- Maryland, 2008", "detail": "www.cdc.gov", "url": "https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5904a3.htm", "authors": "www.cdc.gov", "host": "www.cdc.gov", "snippet": "In the early morning hours of July 9, 2008, six adult family members were admitted to a hospital emergency department in Maryland with hallucinations, confusion, mydriasis, and tachycardia of approximately 3--4 hours duration. Approximately 4--5 hours earlier, all six family members had shared a mea", "score": 0.4811862 }, { "number": 22, "title": "Scopolamine Poisoning among Heroin Users -- New York City,\r\nNewark, Philadelphia, and Baltimore, 1995 and 1996", "detail": "www.cdc.gov", "url": "https://www.cdc.gov/mmwr/preview/mmwrhtml/00042596.htm", "authors": "www.cdc.gov", "host": "www.cdc.gov", "snippet": "During a 24-hour period on December 28-29, 1995, a Newark\nhospital ED treated 22 persons who, approximately 30 minutes after\nusing heroin with the street name \"Polo,\" developed clinical\nmanifestations of anticholinergic toxicity. Naloxone treatment\nincreased agitation and hallucinations, and physost", "score": 0.4187688 }, { "number": 23, "title": "CDC Clinical Practice Guideline for Prescribing Opioids for Pain", "detail": "www.cdc.gov", "url": "https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm", "authors": "www.cdc.gov", "host": "www.cdc.gov", "snippet": "OWG had 23 members (108) including four ex officio members representing federal partner agencies (see Federal Partner Engagement). In accordance with CDC guidance (109,110) that at least two BSC/NCIPC members must serve on OWG and one of the two members must serve as the workgroup chair, OWG include", "score": 0.12529022 }, { "number": 24, "title": "Drug-induced urinary retention: incidence, management and prevention - PubMed", "detail": "www.ccjm.org", "url": "https://www.ccjm.org/lookup/external-ref?access_num=18422378&link_type=MED&atom=%2Fccjom%2F91%2F12%2F762.atom", "authors": "www.ccjm.org", "host": "www.ccjm.org", "snippet": "Urinary retention is a condition in which impaired emptying of the bladder results in postvoidal residual urine. It is generally classified into 'acute' or 'chronic' urinary retention. Because of the complex mechanism of micturition, many drugs can interact with the micturition pathway, all via diff", "score": 0.10426756 } ], "publishedAt": "2026-09-15T23:57:09.050389+00:00", "updatedAt": "2026-09-15T23:57:09.050389+00:00", "readingMinutes": 7, "slug": "anticholinergic-toxicity" }