A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning

Burns, Michael J.; Linden, Christopher H.; Graudins, Andis; Brown, Robert M.; Fletcher, Kenneth E.

doi:10.1016/s0196-0644(00)70057-6

Cited by 208 publications

(152 citation statements)

References 13 publications

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“…We find this of clinical importance in light of studies showing fewer complications when physostigmine is used [7], its proven effectiveness in clearing of delirium [7,8], as well as lower resource utilization [7]. Studies in anesthesia literature have shown a trend towards improvement of delirium without significant safety concerns in controlled settings [11][12][13].…”

Section: Discussionmentioning

confidence: 96%

“…In 2000, Burns et al [7] published a retrospective study of 52 patients who had been referred to a toxicologist and had received either physostigmine, benzodiazepines, or both for a central anticholinergic toxidrome. They found that those who received physostigmine first had fewer complications (7 vs. 47 %) and had their delirium reversed more often (87 % vs. ineffective) when compared with those who received benzodiazepines first.…”

Section: Introductionmentioning

confidence: 99%

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The Use of Physostigmine by Toxicologists in Anticholinergic Toxicity

et al. 2014

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The anticholinergic toxidrome is well described and relatively common. Despite controversy, studies have shown that physostigmine is relatively safe and effective in reversing this toxidrome. We would expect toxicologists would be liberal in its use. We retrospectively analyzed data in the Toxicology Investigators Consortium (ToxIC) registry, representing data from medical toxicologists in multiple institutions nationwide, searching for patients who exhibited an anticholinergic toxidrome, determining what treatment(s) they received, and classifying the treatments as physostigmine, benzodiazepines, physostigmine and benzodiazepines, antipsychotics, or no definitive treatment. The causal agents of the toxidrome were as reported by the treating toxicologist. Eight hundred fifteen consecutive patients with anticholinergic toxidromes were analyzed. Benzodiazepines alone were given in 28.7 %, 12.4 % were given physostigmine alone, 8.8 % received both physostigmine and benzodiazepines, 2.7 % were given antipsychotics, and 47.4 % were given no definitive treatment. In patients who received only physostigmine, there was a significant difference in the rate of intubation (1.9 vs. 8.4 %, OR 0.21, 95 % CI 0.05-0.87) versus other treatment groups. Physostigmine was given at varying rates based on causative agent with use in agents with mixed or unknown effects (15.1 %) being significantly lower than those with primarily anticholinergic effects (26.6 %) (p<0.001). Patients with anticholinergic toxicity were more likely to receive benzodiazepines than physostigmine. Those patients who received only physostigmine had a significantly lower rate of intubation. Physostigmine was more likely to be used with agents exerting primarily anticholinergic toxicity than in those agents with multiple actions.

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Section: Discussionmentioning

confidence: 96%

Section: Introductionmentioning

confidence: 99%

The Use of Physostigmine by Toxicologists in Anticholinergic Toxicity

et al. 2014

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“…Treatments for DPH overdose includes general condition management and symptomatic treatments, such as benzodiazepine (diazepam or midazolam) for convulsions, physostigmine for acetylcholinesterase inhibition, sodium bicarbonate for ventricular arrhythmia, and VA‐ECMO for hemodynamic collapse 4, 5, 9, 10. Although the patient died in this case, it is important to treat unstable hemodynamics with invasive auxiliary circulation such as VA‐ECMO.…”

Section: Discussionmentioning

confidence: 97%

Cardiac arrest caused by diphenhydramine overdose

Nishino

Wakai

Aoki

et al. 2018

Acute Medicine & Surgery

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CaseA 45‐year‐old man presented to our emergency department with disturbance of consciousness; he had mentioned to his family earlier about a drug overdose. When first responders arrived, he suffered cardiac arrest. Cardiac arrest due to drug overdose was diagnosed.The patient was supported with venoarterial extracorporeal membrane oxygenation. Arterial blood gas showed mixed acidosis, and electrocardiogram showed junctional rhythm and complete right bundle branch block.OutcomeThe patient's blood pressure gradually decreased, and he died on the third day of hospitalization. After death, his serum diphenhydramine concentration at the time of arrival was found to be 18.7 μg/mL.ConclusionAlthough diphenhydramine is regarded as a safe medication, it shows dose‐dependent toxicity. High intake is associated with death; therefore, caution should be exercised in cases of drug overdose. Developing a procedure for rapid measurement in the emergency department should be a priority.

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“…Similarly, delirium was considered to be present if the patient was less than fully oriented or had "delirium," "delirious," "incoherent," "incomprehensible," "mumbling," or "mumbled" speech documented in the record [2].…”

Section: Methods Of Measurement and Data Collecting/processingmentioning

confidence: 99%

“…Today, physostigmine is a diagnostic and therapeutic antidote that can reverse the agitated delirium and tachycardia of antimuscarinic poisoning (i.e., antimuscarinic toxidrome) [2]. The antimuscarinic toxidrome results from blockade of the neurotransmitter acetylcholine at central and peripheral muscarinic receptors, leading to varying degrees of tachycardia, agitation, delirium, dilated pupils, dry mucous membranes, dry skin, and hypoactive bowel sounds [3].…”

Section: Introductionmentioning

confidence: 99%

Timing and Frequency of Physostigmine Redosing for Antimuscarinic Toxicity

Rosenbaum

Bird

2010

J. Med. Toxicol.

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We sought to determine how frequently antimuscarinic-poisoned patients receiving physostigmine receive multiple doses of physostigmine, the length of time between physostigmine doses, and what impact multiple doses of physostigmine have on the disposition and total length of hospital stay. We performed a retrospective chart review of patients given physostigmine for likely antimuscarinic toxicity. A total of 45 patients met inclusion criteria. We abstracted patient demographics, vital signs, physical exam findings, electrocardiograms, the timing and dose of physostigmine, the implicated antimuscarinic agents, and disposition from the hospital. We counted the number of patients who required multiple physostigmine doses and calculated the time to repeat dosing. Fourteen of the 45 patients (31%) given physostigmine for antimuscarinic toxicity received multiple doses: nine patients (20%) received two doses, three patients (6.6%) received three doses, and two patients (4.4%) received four doses. Less than 5.5 h elapsed between sequential physostigmine doses, and less than 6.5 h elapsed between the first and last dose. Forty-five percent of patients receiving one dose of physostigmine were discharged from the emergency department (ED) and 36% of patients receiving more than one dose of physostigmine were discharged from the ED. Whether admitted or discharged, there was no statistically significant difference in the length of hospital stay between patients receiving one or multiple doses of physostigmine.Repeated physostigmine administration is not frequently needed in medication-induced antimuscarinic toxicity. Patients are not likely to require further physostigmine redosing more than 6.5 h from their first dose.

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A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning

Cited by 208 publications

References 13 publications

The Use of Physostigmine by Toxicologists in Anticholinergic Toxicity

The Use of Physostigmine by Toxicologists in Anticholinergic Toxicity

Cardiac arrest caused by diphenhydramine overdose

Timing and Frequency of Physostigmine Redosing for Antimuscarinic Toxicity

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