Physostigmine effectively reverses anticholinergic delirium. However, continuous IV infusion of physostigmine is rarely used due to concern for cardiotoxicity and signs of cholinergic excess such as seizures, nausea, and vomiting. We report the successful use of continuous IV physostigmine in a 6-year-old boy with anticholinergic delirium. A 6-year-old, 30-kg boy with attention deficit hyperactivity disorder (ADHD) ingested 15-20 olanzapine (5 mg) tablets. He was agitated and was treated with lorazepam at a local hospital. His heart rate was 148 beats per min; respiratory rate, 32 breaths per minute; blood pressure, 111/70 mmHg; temperature, 96.8°F, and O2 saturation of 98% on room air. His pupils were 5-6 mm, and his skin was warm and initially flushed. Blood chemistry results were normal. A 12-lead ECG showed sinus tachycardia with normal QRS and QT intervals. The agitation worsened and did not respond to benzodiazepines. The patient was then given a dose of 0.6 mg physostigmine (0.02 mg/kg) intravenously with reversal of the agitation. But the effect only lasted 45 min requiring administration of a second bolus of 0.6 mg (0.02 mg/kg). A physostigmine intravenous infusion was administered at a rate of 0.5 mg/h (0.0167 mg/kg/h). Overnight, the patient became more agitated. The physostigmine was discontinued, and IV dexmedetomidine (0.2 μg/kg/h) was started at 21:00. The patient became over-sedated with pinpoint pupils resulting in discontinuation of the dexmedetomidine at 04:00. The patient again became agitated and developed visual hallucinations. Three 1-mg (0.03 mg/kg) boluses of physostigmine were administered over 45 min, and the physostigmine infusion was restarted at a rate of 1 mg/h (0.03 mg/kg/h) for 16.5 h. He received 19.5 mg of physostigmine with no return of anticholinergic symptoms and no signs of cholinergic excess except for a tremor that resolved when the infusion was stopped. He was discharged home without further sequelae. There are few publications describing a continuous infusion of physostigmine to reverse anticholinergic delirium. Our patient received a total dose of 25.5 mg with complete resolution of symptoms. We report the successful use of continuous infusion of physostigmine to reverse anticholinergic delirium in a pediatric patient who unintentionally ingested olanzapine.
Introduction Restrained subjects often spit on law enforcement and corrections officers and medical responders. Based on the droplet-transmitted risk of COVID-19, such spitting could be considered a potentially life-threatening assault. Officers commonly use “spit socks” over the head and neck of spitting subjects to reduce this risk. The pneumatic impedance of such socks has not been published, so this remains an open issue for arrest-related death investigation. Methods We purchased samples of 3 popular spit sock models, 3 insect-protecting “bug” socks and hats, 3 N95 masks, a standard 3-ply surgical mask, and a common dust mask. We used a BTmeter model BTN8468 digital anemometer, an HTI model HT-1890 digital manometer, and an AC Infinity Cloudline model S6 inline controllable fan to measure air flow versus pressure drop. We compared the curves graphically and also calculated a pneumatic pseudo-impedance by dividing the pressure drop by the air velocity. Results The spit and bug socks allowed nearly maximum airflow with minimal pressure (≤1 mm Hg), whereas none of the masks allowed greater than 2 m/s of airflow at maximum pressure of 3 mm Hg. All of the spit and bug masks were grouped together with the lowest pneumatic impedances, whereas all of the N95 masks were grouped together with the highest values. The dust mask and surgical mask were in between with the dust mask closer to the spit and bug masks, whereas the surgical mask was closer to the N95 masks in impedance. Conclusions Commonly used spit socks offer nearly zero resistance to breathing. The highest resistance spit sock was still 100 times better than the best N95 mask for airflow during inhalation. Our results do not support the occasional hypothesis that spit socks might contribute to an arrest-related death.
It has been suggested that a CEW (conducted electrical weapon) exposure could elicit a stress response that could cause ExDS (excited delirium syndrome). There are some parallels between the signs of ExDS and serotonin syndrome (SS). Electroconvulsive therapy raises serotonin levels and therefore provides a plausible link between CEW applications and elevated serotonin levels. This study was designed to determine whether a CEW exposure elevates serum serotonin. A total of 31 police academy cadets were exposed to a very broad-spread 5-s CEW stimulus from a TASER brand X26 CEW. Blood was drawn before and after the exposure and at 24 h post exposure to measure serum serotonin levels. Lactic acid and cortisol levels were also compared. Median serum serotonin levels were 30 IQR (21,46), 36 IQR (22,50), and 32 IQR (21,45) ng/mL before exposure, after exposure, and 24 h after exposure (NS by pooled comparisons). The increase from baseline to post-test serotonin (∆ median = +6, ∆ mean = +2.7) ng/mL was not significant by a paired T-test (p = .29) but was significant by the Wilcoxon signed-rank test (p = .037). The increase to post-test log serotonin was not significant by a paired T-test (p = .13) but was significant by the Wilcoxon test (p = .049). All serotonin levels remained within the normal reference range of 0-200 ng/mL. Post-hoc analysis demonstrated that the study was powered to detect a ½ SD change, in log serotonin, with a 90% likelihood. With a very-broad electrode spread, CEW exposure did not significantly raise serum serotonin levels.
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