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Use of a physostigmine continuous infusion for the treatment of severe and recurrent antimuscarinic toxicity in a mixed drug overdose.
J Med Toxicol. 2014 Jun; 10(2):205-9.JM

Abstract

INTRODUCTION

Physostigmine was once a widely used antidote for the treatment of antimuscarinic toxicity. However, reports describing the association of physostigmine with asystole and seizures in severe tricyclic antidepressant poisoning resulted in a decrease in use. Recent literature has demonstrated that physostigmine is a safe and effective antidote for the treatment of antimuscarinic toxicity. There are only two previously published articles regarding the use of physostigmine administered as a continuous intravenous infusion for persistent antimuscarinic toxicity. We present a case of physostigmine continuous infusion for the treatment of antimuscarinic symptoms in a polydrug overdose due to the ingestion of diphenhydramine along with bupropion, citalopram, acetaminophen, and naproxen.

CASE PRESENTATION

A 13-year-old female presented with hyperthermia, myoclonus and rigidity, hallucinations, severe agitation, and antimuscarinic toxicity including inability to sweat after a polydrug overdose. Several doses of lorazepam were administered followed by physostigmine which produced resolution of hallucinations and attenuation of the antimuscarinic symptoms including perspiration, temperature improvement, and decreased agitation. After periods of improvement and recurrence of antimuscarinic effects, a continuous infusion of physostigmine was administered at 2 mg/h and continued for almost 8 h to maintain attenuation of symptoms. GABAergic agents including lorazepam and phenobarbital were used later in the hospital course for presumed symptoms of serotonergic and adrenergic toxicity after resolution of antimuscarinic effects. The patient did not experience any adverse effects of physostigmine administration.

DISCUSSION

Physostigmine administered as a continuous infusion may be a reasonable treatment option for severe and recurrent symptoms related to antimuscarinic toxicity.

Authors+Show Affiliations

Department of Pharmacy, University of Rochester Medical Center, 601 Elmwood Ave., Box 638, Rochester, NY, 14642, USA.No affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Case Reports
Journal Article

Language

eng

PubMed ID

24798647

Citation

Phillips, Michelle A., et al. "Use of a Physostigmine Continuous Infusion for the Treatment of Severe and Recurrent Antimuscarinic Toxicity in a Mixed Drug Overdose." Journal of Medical Toxicology : Official Journal of the American College of Medical Toxicology, vol. 10, no. 2, 2014, pp. 205-9.
Phillips MA, Acquisto NM, Gorodetsky RM, et al. Use of a physostigmine continuous infusion for the treatment of severe and recurrent antimuscarinic toxicity in a mixed drug overdose. J Med Toxicol. 2014;10(2):205-9.
Phillips, M. A., Acquisto, N. M., Gorodetsky, R. M., & Wiegand, T. J. (2014). Use of a physostigmine continuous infusion for the treatment of severe and recurrent antimuscarinic toxicity in a mixed drug overdose. Journal of Medical Toxicology : Official Journal of the American College of Medical Toxicology, 10(2), 205-9. https://doi.org/10.1007/s13181-013-0330-y
Phillips MA, et al. Use of a Physostigmine Continuous Infusion for the Treatment of Severe and Recurrent Antimuscarinic Toxicity in a Mixed Drug Overdose. J Med Toxicol. 2014;10(2):205-9. PubMed PMID: 24798647.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Use of a physostigmine continuous infusion for the treatment of severe and recurrent antimuscarinic toxicity in a mixed drug overdose. AU - Phillips,Michelle A, AU - Acquisto,Nicole M, AU - Gorodetsky,Rachel M, AU - Wiegand,Timothy J, PY - 2014/5/7/entrez PY - 2014/5/7/pubmed PY - 2015/2/13/medline SP - 205 EP - 9 JF - Journal of medical toxicology : official journal of the American College of Medical Toxicology JO - J Med Toxicol VL - 10 IS - 2 N2 - INTRODUCTION: Physostigmine was once a widely used antidote for the treatment of antimuscarinic toxicity. However, reports describing the association of physostigmine with asystole and seizures in severe tricyclic antidepressant poisoning resulted in a decrease in use. Recent literature has demonstrated that physostigmine is a safe and effective antidote for the treatment of antimuscarinic toxicity. There are only two previously published articles regarding the use of physostigmine administered as a continuous intravenous infusion for persistent antimuscarinic toxicity. We present a case of physostigmine continuous infusion for the treatment of antimuscarinic symptoms in a polydrug overdose due to the ingestion of diphenhydramine along with bupropion, citalopram, acetaminophen, and naproxen. CASE PRESENTATION: A 13-year-old female presented with hyperthermia, myoclonus and rigidity, hallucinations, severe agitation, and antimuscarinic toxicity including inability to sweat after a polydrug overdose. Several doses of lorazepam were administered followed by physostigmine which produced resolution of hallucinations and attenuation of the antimuscarinic symptoms including perspiration, temperature improvement, and decreased agitation. After periods of improvement and recurrence of antimuscarinic effects, a continuous infusion of physostigmine was administered at 2 mg/h and continued for almost 8 h to maintain attenuation of symptoms. GABAergic agents including lorazepam and phenobarbital were used later in the hospital course for presumed symptoms of serotonergic and adrenergic toxicity after resolution of antimuscarinic effects. The patient did not experience any adverse effects of physostigmine administration. DISCUSSION: Physostigmine administered as a continuous infusion may be a reasonable treatment option for severe and recurrent symptoms related to antimuscarinic toxicity. SN - 1937-6995 UR - https://wwww.unboundmedicine.com/medline/citation/24798647/Use_of_a_physostigmine_continuous_infusion_for_the_treatment_of_severe_and_recurrent_antimuscarinic_toxicity_in_a_mixed_drug_overdose_ DB - PRIME DP - Unbound Medicine ER -