Anticholinergic Toxicity Clinical Presentation
- Author: John J Bruns Jr, MD, MPH,†; Chief Editor: Asim Tarabar, MD more...
History
- For all patients with suspected poisoning, determine the precise substance(s) ingested, time of ingestion, quantity ingested, rationale for ingestion, and co-ingestants.
- Ascertain patient compliance, medical history, prescription medications, and nonprescription medications (including natural or herbal products).
- Many medications have anticholinergic properties, which can result in additive toxicity.
- Always inquire about use of dermally applied drugs (ie, scopolamine transdermal delivery system).
Physical
- Anticholinergic syndrome results from the inhibition of muscarinic cholinergic neurotransmission.
- Clinical manifestations are caused by CNS effects, peripheral nervous system effects, or both.
- Remember common signs and symptoms with the mnemonic, "red as a beet, dry as a bone, blind as a bat, mad as a hatter, and hot as a hare." The mnemonic refers to the symptoms of flushing, dry skin and mucous membranes, mydriasis with loss of accommodation, altered mental status (AMS), and fever, respectively.
- Additional manifestations include sinus tachycardia, decreased bowel sounds, functional ileus, urinary retention, hypertension, tremulousness, and myoclonic jerking.
- Patients with central anticholinergic syndrome may present with ataxia, disorientation, short-term memory loss, confusion, hallucinations (visual, auditory), psychosis, agitated delirium, seizures (rare), coma, respiratory failure, and cardiovascular collapse.
Causes
Agents with anticholinergic properties are as follows:
- Anticholinergics
- Atropine, scopolamine
- Glycopyrrolate
- Benztropine, trihexyphenidyl
- Antihistamines
- Chlorpheniramine
- Cyproheptadine
- Doxylamine
- Hydroxyzine
- Dimenhydrinate
- Diphenhydramine
- Meclizine
- Promethazine
- Antipsychotics
- Chlorpromazine
- Clozapine
- Mesoridazine
- Olanzapine
- Quetiapine
- Thioridazine
- Antispasmodics
- Clidinium
- Dicyclomine
- Hyoscyamine
- Oxybutynin
- Propantheline
- Cyclic antidepressants
- Amitriptyline
- Amoxapine
- Clomipramine
- Desipramine
- Doxepin
- Imipramine
- Nortriptyline
- Protriptyline
- Mydriatics
- Cyclopentolate
- Homatropine
- Tropicamide
- Plants
- Amanita muscaria (fly agaric)
- Amanita pantherina (panther mushroom)
- Arctium lappa (burdock root)
- Atropa belladonna (deadly nightshade)
- Cestrum nocturnum (night blooming jessamine)
- Datura suaveolens (angel's trumpet)
- Datura stramonium (jimson weed)
- Hyoscyamus niger (black henbane)
- Lantana camara (red sage)
- Solanum carolinensis (wild tomato)
- Solanum dulcamara (bittersweet)
- Solanum pseudocapsicum (Jerusalem cherry)
- Solanum tuberosum (potato)
- Miscellaneous, including carbamazepine, cyclobenzaprine, and orphenadrine
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