Version May 2024
| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links). |
| Clinical and laboratory features |
| Anticholinergic toxicity is almost always a clinical diagnosis |
| Manifestations of anticholinergic toxicity include: |
| Flushing due to cutaneous vasodilation ("red as a beet") |
| Anhydrosis ("dry as a bone") |
| Hyperthermia due to loss of sweating ("hot as a hare") |
| Blurry vision due to nonreactive mydriasis and paralysis of accommodation ("blind as a bat") |
| Agitated delirium ("mad as a hatter") |
| Urinary retention ("full as a flask") |
| Decreased bowel sounds |
| Tachycardia |
| Diagnosis |
| Check fingerstick glucose, ECG, acetaminophen and salicylate levels, and a qualitative pregnancy test in poisoned patients |
| A serum creatine kinase and renal function testing (BUN and creatinine) are appropriate in patients in whom rhabdomyolysis is suspected |
| No laboratory findings or diagnostic laboratory tests can definitively determine anticholinergic toxicity |
| A trial of physostigmine (see Treatment below) will help establish or rule out the diagnosis of anticholinergic toxicity |
| Treatment |
| Secure the airway, breathing, and circulation |
| Patients who manifest both peripheral AND moderate central (moderate to severe agitation/delirium) anticholinergic toxicity, without contraindications to physostigmine, should be treated with this medication; dose: 0.5 to 2 mg (0.02 mg/kg IV, up to a maximum of 0.5 mg per dose in pediatric patients); physostigmine should be given by slow IV push, generally over five minutes |
| Treat agitation and seizures with benzodiazepines (eg, lorazepam 1 to 2 mg IV push [pediatric dose 0.1 mg/kg up to 2 mg maximum single dose]; may repeat as needed); DO NOT use phenothiazines or butyrophenones (eg, haloperidol) |
| Give activated charcoal (1 g/kg; maximum 50 g) to patients with intact mental status or a secure airway and likely ingestion of an anticholinergic agent |
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