II. Causes: General
- Medications (see below)
- See Anticholinergic Medications
- Antihistamines
- Tricyclic Antidepressants
- Phenothiazines
- Parasympatholytic medications
- Toxins
- Incapacitating Agents (e.g. BZ)
- Botulism (or infant bolulism)
- Ingested items (Belladonna Poisoning)
- Jimsonweed or Thorn-Apple (Datura stramonium)
- Amanita muscaria mushrooms
- Deadly Nightshade
- Devil's Apple (Solanum linnaeanum)
III. Causes: Muscarinic Anticholinergic effects (most Anticholinergic first)
- Atropine (100% of maximal Anticholinergic effect)
- Scopolamine
- Tolterodine
- Hyoscyamine
- Cholinergic Parkinsonism agents
- Prednisone (55%)
-
Diphenhydramine (Benadryl)
- DiphenhydramineOverdose is responsible for >3% of U.S. Overdose deaths (within top 15 drugs)
- Mild Overdose
- Causes sedation and muscarinic Anticholinergic Toxicity (Dry Mouth, Tachycardia, Mydriasis)
- Severe Overdose
- Causes Agitation, Delirium, Hallucinations, Seizures and coma
- Diphenhydramine blocks myocardial Sodium and Potassium channels (Wide QRS, QTc Prolongation)
- Amitriptyline (Elavil)
- Digoxin
- Nifedipine
- Phenobarbital
- Oxybutynin (20%)
- Isosorbide Dinitrate
- Hydroxyzine
- Warfarin
- Dipyridamole
- Codeine
- Ranitidine (10%)
- Dyazide
- Furosemide (Lasix)
- Nortriptyline (3%)
IV. Symptoms: Mnemonic (antimuscarinic)
V. Symptoms: Complete List (antimuscarinic)
-
Altered Level of Consciousness
- Speech may be soft spoken, or a mumbling Word Salad
- Hallucinations
- Delirium
- Coma
- Seizures
- Sinus Tachycardia (may approach 150 bpm in adults)
- Hypertension
- Hyperthermia (typically low grade fever)
-
Dry Skin
- Examine axilla and groin (where dryness is uncommon)
- Contrast with Sympathomimetic Toxicity in which skin is diaphoretic
-
Dry Mouth
- Speech may sound muffled as if cotton balls are in mouth
- Mydriasis with Blurred Vision
- Decreased bowel sounds
- Constipation
- Urinary Retention
VI. Differential Diagnosis
VII. Labs
- See Unknown Ingestion
- See Altered Level of Consciousness
-
Creatine Kinase (CK)
- Monitor for Rhabdomyolysis with serial measurements
VIII. Diagnostics: Electrocardiogram
- Observe for EKG abnormalities (Intraventricular Conduction Delay)
- Prolonged QTc
- Wide QRS interval
- Exclude contraindications to Physostigmine (esp. Tricyclic Antidepressant Overdose)
- Bradycardia
- Intraventricular conduction delay (Wide QRS)
- AV Nodal block
- Terminal R (wide R Wave >3 mm) in AVR (suggests Sodium channel blockade, seen in TCA Overdose)
IX. Management
-
Gastric Decontamination
- Indicated in specific ingestions (e.g. Diphenhydramine) presenting within 2 hours and no contraindications (e.g. ALOC)
-
Agitation may require treatment
- See Sedation in Excited Delirium
- Preferred sedation agents
- Benzodiazepines
- Dexmedetomidine (Precedex)
- Propofol could also be used (short course)
- Avoid Physical Restraints
- Risk of worsening Rhabdomyolysis
- Avoid Antipsychotics (e.g. Haloperidol)
- Risk of upsetting Temperature Regulation (with worsening hyperthermia)
-
Seizures
- See Status Epilepticus
- Benzodiazepines are preferred for Anticholinergic induced Seizures
- Control hyperthermia
- Monitor Temperature
- Consider Temperature-sensing Foley Catheter
- Other measures refractory to Benzodiazepines and other Sedatives
- Paralysis could be considered (rare cases)
- Monitor Temperature
- Intravenous Fluids
- Intraventricular Conduction Delay on EKG
- Child or Teen with QRS interval > 100 ms, QTc Interval > 460 ms
- Administer Sodium Bicarbonate 1 mEq/kg IV and repeat as needed until improved QRS, QTc
- Initiate Sodium Bicarbonate infusion if more than 2 doses of Sodium Bicarbonate are needed
- Antidote: Physostigmine
- See Physostigmine for dosing and contraindications
- Repeat dosing may be needed (lasts only 30 minutes)
- Consider Physostigmine in cases of Altered Level of Consciousness and signs of Anticholinergic Toxicity
- Physostigmine will transiently reverse Anticholinergic effects and aid diagnosis in unclear cases
- Review contraindications before administration
- Obtain EKG prior to administration
- Exclude Bradycardia, intraventricular conduction delay or AV Nodal block
- Avoid in Tricyclic Antidepressant Overdose (risk of Asystole)
- Contraindicated in uncontrolled Asthma or Wheezing
- Contraindicated in Seizure Disorder
- Contraindicated in Bowel Obstruction
- Contraindicated in polysubstance Overdose
- Obtain EKG prior to administration
- References
- Claudius and Levine in Majoewsky (2012) EM:Rap 12(5): 7
X. References
- Orman and Hatten in Herbert (2016) EM:Rap 16(4): 6
- Swaminathan and Monas in Herbert (2020) EM:Rap 20(5):1
- Lacey and Dietrich (2023) Crit Dec Emerg Med 37(3): 18-9
Images: Related links to external sites (from Bing)
Related Studies
| Definition (MSH) | Adverse drug effects associated with CHOLINERGIC ANTAGONISTS. Clinical features include TACHYCARDIA; HYPERTHERMIA; MYDRIASIS, dry skin and dry mucous membranes, decreased bowel sounds and urinary retention in peripheral anticholinergic syndrome; and HALLUCINATIONS; PSYCHOSES; SEIZURES; and COMA in central anticholinergic syndrome. |
| Definition (MSHCZE) | Soubor příznaků způsobený otravou látkami s anticholinergním účinkem (např. atropin, skopolamin, antidepresiva, antipsychotika, antihistaminika, antiparkinsonika aj.). K projevům patří tachykardie, zvýšená teplota, suchá, zarudlá kůže, rozšířené zornice, svalové záškuby a retence moči. Léčba je podpůrná včetně dekontaminace, protijedem antidotem je fysostigmin. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ ) |
| Concepts | Disease or Syndrome (T047) |
| MSH | D064807 |
| SnomedCT | 2233003 |
| English | ANTICHOLINERGIC SYNDROME, Anticholinergic syndrome, Syndrome anticholinergic, Atropine-like syndrome, Syndrome atropine-like, Syndrome parasympatholytic, Anticholinergic Syndrome, Anticholinergic Syndromes, Syndromes, Anticholinergic, Syndrome, Anticholinergic, Anticholinergic Syndrome [Disease/Finding] |
| Dutch | syndroom anticholinerg, syndroom parasympatholytisch, atropineachtig syndroom, syndroom atropineachtig, anticholinerg syndroom |
| French | Syndrome de type atropine, Syndrome atropinique, Syndrome parasympatholytique, SYNDROME ANTICHOLINERGIQUE, Syndrome anticholinergique |
| German | Syndrom atropinartig, atropinartiges Syndrom, Syndrom anticholinerg zentral, Syndrom parasympatholytisch, ANTICHOLINERGER EFFEKT, Anticholinerges Syndrom, anticholinerges Syndrom |
| Italian | Sindrome atropino-simile, Sindrome parasimpaticolitica, Sindrome anticolinergica |
| Portuguese | Síndrome tipo atropínico, Síndrome tipo atropina, Síndrome parassimpaticolítica, SINDROME ANTICOLINERGICO, Síndrome anticolinérgica |
| Spanish | Síndrome parasimpaticolítico, Síndrome tipo atropínico, ANTICOLINERGICO, SINDROME, síndrome anticolinérgico, Síndrome anticolinérgico |
| Japanese | アトロピン様症候群, 抗コリン作動性症候群, 副交感神経遮断症候群, ｺｳｺﾘﾝｻﾄﾞｳｾｲｼｮｳｺｳｸﾞﾝ, ﾌｸｺｳｶﾝｼﾝｹｲｼｬﾀﾞﾝｼｮｳｺｳｸﾞﾝ, ｱﾄﾛﾋﾟﾝﾖｳｼｮｳｺｳｸﾞﾝ |
| Czech | Parasympatolytický syndrom, Syndrom jako atropinový, Anticholinergní syndrom, anticholinergní syndrom |
| Hungarian | Atropin-szerű syndroma, Anticholinergiás syndroma, Anticholinerg syndroma, Atropin-szerű tünetegyüttes, Parasympatholytikus syndroma |
| Norwegian | Antikolinergt syndrom |
| Russian | АНТИХОЛИНЕРГИЧЕСКИЙ СИНДРОМ, ХОЛИНОЛИТИЧЕСКИЙ СИНДРОМ, KHOLINOLITICHESKII SINDROM, ANTIKHOLINERGICHESKII SINDROM |
Ontology: anticholinergic toxicity (C0237996)
| Concepts | Injury or Poisoning (T037) |
| English | anticholinergic toxicity (diagnosis), anticholinergic toxicity, toxicity from anticholinergics, anticholinergics toxicity |
Ontology: Poisoning by antimuscarinic drug (C0274708)
| Concepts | Injury or Poisoning (T037) |
| SnomedCT | 74338006 |
| English | Poisoning by antimuscarinic drug (disorder), Poisoning by antimuscarinic drug, Poisoning by antimuscarinic drug, NOS |
| Spanish | intoxicación por droga antimuscarínica (trastorno), intoxicación por droga antimuscarínica |
Ontology: Anticholinergic adverse reaction (C0569703)
| Concepts | Injury or Poisoning (T037) |
| SnomedCT | 292522009 |
| English | Anticholinergic adverse react, adverse effect of ANS drug therapy anticholinergics, adverse effect of anticholinergics, adverse reaction to anticholinergics, adverse effect of anticholinergics (diagnosis), Anticholinergic adverse reaction, Anticholinergic adverse reaction (disorder) |
| Spanish | reacción adversa a fármaco anticolinérgico (trastorno), reacción adversa a fármaco anticolinérgico |
Ontology: Anticholinergic syndrome (SMQ) (C1869050)
| Definition (MDRCZE) | Anticholinergní syndrom je stav zmatenosti s charakteristickými rysy týkajícími se dysfunkce autonomního parasympatetického (cholinergního) nervového systému. Symptomy se klasifikují do manifestací v systému a CNS: Systémové (perifení) symptomy: rozmazané vidění, fotofobie, nereaktivní mydriáza, ztráta akomodační reakce, zrudlá a suchá pokožka, sucho v ústech, tachykardie, vysoký krevní tlak a horečka. Gastrointestinální a močová motilita jsou často sníženy. Centrální anticholinergní syndrom je akutní obraz podobný akutní psychóze, charakterizovaný deliriem, rozrušením, dezorientací a zrakovými halucinacemi. Ataxie, choreoatetóza, myoklon a záchvaty mohou také nastávat bez periferních symptomů. |
| Definition (MDRHUN) | Az anticholinergiás syndroma egy zavarodott állapot a vegetatív paraszimpatikus (cholinergiás) idegrendszer működési zavarához kapcsolódó jellemző vonásokkal. Tünetek osztályozása szisztémás és CNS megnyilvánulásokba: Szisztémás (perifériás) tünetek: homályos látás, photophobia, nem reaktív mydriasis, alkalmazkodási reakció elvesztése, kipirult és száraz bőr, száraz száj, tachycardia, hypertensio és láz. A gastrointestinalis és húgyúti motilitás gyakran csökken. A központi antikolinerg syndroma egy akut pszichozisszerű kép, melyet delirium, nyugtalanság, tájékozódási zavar és vizuális hallucinációk jellemzik. Előfordulhat ataxia, choreoathetosis, myoclonus és rohamok is perifériás tünetek nélkül. |
| Definition (MDR) | Anticholinergic syndrome is a confusional state with characteristic features related to dysfunction of the autonomic parasympathetic (cholinergic) nervous system. Symptoms classified into systemic and CNS manifestations: Systemic (peripheral) symptoms: blurred vision, photophobia, nonreactive mydriasis, loss of accommodation response, flushed and dry skin, dry mouth, tachycardia, hypertension and fever. Gastrointestinal and urinary motility are frequently reduced. Central Anticholinergic Syndrome is an acute psychosis-like picture characterized by delirium, agitation, disorientation, and visual hallucinations. Ataxia, choreoathetosis, myoclonus and seizures may also occur without peripheral symptoms. |
| Definition (MDRSPA) | El síndrome anticolinérgico es un estado confusional cuyas características están relacionadas con la disfunción de las fibras parasimpáticas (colinérgicas) del sistema nervioso autónomo. Los síntomas están clasificados en manifestaciones sistémicas y en el SNC: Síntomas sistémicos (periféricos): visión borrosa, fotofobia, midriasis no reactiva, pérdida de respuesta a la acomodación, piel enrojecida y seca, boca seca, taquicardia, hipertensión y fiebre. La motilidad gastrointestinal y del tracto urinario se reduce con frecuencia. El síndrome anticolinérgico central es un cuadro agudo de seudopsicosis caracterizado por delirio, agitación, desorientación y alucinaciones visuales. Además, puede presentarse ataxia, coreoatetosis, mioclonías y convulsiones sin síntomas periféricos. |
| Definition (MDRITA) | La sindrome anticolinergica è uno stato confusionale che include aspetti caratteristici correlati alla disfunzione del sistema nervoso autonomico parasimpatico (colinergico).Sintomi classificati come manifestazioni sistemiche e del SNC: sintomi sistemici (periferici): visione offuscata, fotofobia, midriasi non reattiva, perdita della riflesso di accomodazione, pelle arrossata e secca, bocca secca, tachicardia, ipertensione e febbre. Frequente riduzione della motilità gastrointestinale e urinaria. La sindrome anticolinergica centrale è un manifestazione acuta simile alla psicosi caratterizzata da delirio, agitazione, disorientamento e allucinazioni visive. Atassia, coreoatetosi, mioclono e convulsioni possono anche essere presenti senza sintomi periferici. |
| Definition (MDRFRE) | Le syndrome anticholinergique est un état confusionnel présentant des caractéristiques particulières associés à un dysfonctionnement du système nerveux parasympathique (cholinergique) autonome. Les symptômes sont classés en manifestations systémiques et manifestations du SCN : Symptômes systémiques (périphériques) : vision trouble, photophobie, mydriase non réactive, perte du réflexe d'accommodation, rougeur et sécheresse cutanées, bouche sèche, tachycardie, hypertension et fièvre. La motilité gastro-intestinale et urinaire sont fréquemment réduites. Le syndrome anticholinergique central produit un tableau de type psychose aiguë caractérisé par des manifestations de délire, agitation, désorientation et hallucinations visuelles. Ataxie, choréoathétose, myoclonie et crises peuvent également survenir sans symptômes périphériques. |
| Definition (MDRDUT) | Anticholinergisch syndroom is een verwardheidstoestand met karakteristieke eigenschappen met betrekking tot disfunctie van het parasympathische (cholinerge) autonome zenuwstelsel. Symptomen geclassificeerd als systemische manifestaties en manifestaties van het zenuwstelsel: Systemische (perifere) symptomen: wazig zien, fotofobie, niet-reactieve mydriase, verlies van accommodatiereactie, overmatig blozende en droge huid, droge mond, tachycardie, hypertensie en koorts. Maagdarmen urinewegmotiliteit zijn vaak verminderd. Centraal anticholinergisch syndroom is een acuut psychoseachtig beeld gekenschetst door delirium, agitatie, disoriëntatie en visuele hallucinaties. Ataxie, choreoathetose, myoclonus en insulten kunnen zich ook voordoen zonder perifere symptomen. |
| Definition (MDRGER) | Das anticholinerge Syndrom ist ein Verwirrungszustand mit charakteristischen Merkmalen, die mit der Dysfunktion des autonomen parasympathetischen (cholingergischen) Nervensystems zusammenhängen. Symptome, die als systemische und CNS-Manifestationen klassifiziert sind: Systemische (periphere) Symptome: unscharfe Sicht, Photophobie, nicht reaktive Mydriase, Verlust der Akkomodationsreaktion, gerötete und trockene Haut, trockener Mund, Tachykardie, Hypertonie und Fieber. Gastrointestinale und urinäre Motilität ist oft verringert. Zentralanticholinerges Syndrom ist ein aktues psychoseartiges Bild gekennzeichnet von Delirium, Unruhe, Desorientierung und visuellen Halluzinationen. Ataxie, Choreoathetose, Myoklonus und Krämpfe können auch ohne periphere Symptome auftreten. |
| Definition (MDRPOR) | A síndrome anticolinérgica é um estado confusional cujas características estão relacionadas com a disfunção das fibras parasimpáticas (colinérgicas) do sistema nervoso autónomo. Os sintomas estão classificados em manifestações sistémicas e no SNC: Sintomas sistémicos (periféricos): visão enevoada, fotofobia, midríase não reactiva, perda de resposta à acomodação, pele avermelhada e seca, boca seca, taquicardia, hipertensão e febre. A motilidade gastrointestinal e do tracto urinário reduz-se se com frequência. A síndrome anticolinérgica central é um quadro agudo de pseudo psicose caracterizado por delírio, agitação, desorientação e alucinações visuais. Além disso, também podem ocorrer ataxia, coreoatetose, mioclonias e convulsões sem sintomas periféricos. |
| Definition (MDRJPN) | 抗コリン作動性症候群は、自律神経の副交感（コリン作動性）神経系の機能不全に関連する特徴を有する錯乱状態である。症状は全身性および中枢神経系症状に分類される。全身性（末梢神経性）症状には、霧視、羞明、非反応性散瞳、遠近調節反応の消失、皮膚の潮紅および乾燥、口渇、頻脈、高血圧、および発熱がある。消化管および尿管の運動性が頻回に低下する。中枢神経性抗コリン作動性症候群は、急性の精神病様病像を呈し、譫妄、激越、失見当識、および幻視を特徴とする。運動失調、舞踏病アテトーシス、ミオクローヌス、および発作もまた、末梢神経性症状を伴わずにみられる。 |
| Concepts | Classification (T185) |
| English | Anticholinergic syndrome (SMQ) |
| Dutch | Anticholinergisch syndroom (SMQ) |
| French | Syndrome anticholinergique (SMQ) |
| German | Anticholinerges Syndrom (SMQ) |
| Italian | Sindrome anticolinergica (SMQ) |
| Spanish | Síndrome anticolinérgico (SMQ) |
| Portuguese | Síndrome anticolinérgica (SMQ) |
| Czech | Anticholinergní syndrom (SMQ) |
| Japanese | 抗コリン作動性症候群（ＳＭＱ） |
| Hungarian | Anticholinergiás syndroma (SMQ) |
