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1.
Lakartidningen ; 1162019 Sep 25.
Artigo em Sueco | MEDLINE | ID: mdl-31573667

RESUMO

Sometimes it is suspected that people have been involuntary exposed to drugs, usually by spiked drinks. A young woman was transported to an emergency department by ambulance. Her clinical symptoms (decreased consciousness, mydriasis, confusion, hallucinations and urine retention) indicated anticholinergic syndrome that was effectively treated with the antidote physostigmine. A urine sample tested negative for common narcotic drugs and alcohol, but an extended toxicological analysis of the urine revealed the presence of the alkaloid scopolamine. Scopolamine occurs naturally in Solanaceae plants and is used in some medications. The woman reported that the symptoms had appeared soon after she was offered tea by a male acquaintance. The analytical results along with the woman's story indicated that she had been subjected to a drug-facilitated crime. The results further demonstrate that in suspected cases of involuntary drug exposure, testing should cover a wide panel of relevant drugs, otherwise poisoning may be missed.


Assuntos
Antagonistas Colinérgicos , Escopolamina , Detecção do Abuso de Substâncias , Adolescente , Adulto , Síndrome Anticolinérgica/tratamento farmacológico , Síndrome Anticolinérgica/etiologia , Antídotos/uso terapêutico , Antagonistas Colinérgicos/envenenamento , Antagonistas Colinérgicos/urina , Cromatografia Líquida de Alta Pressão , Vítimas de Crime , Feminino , Humanos , Espectrometria de Massas , Fisostigmina/uso terapêutico , Escopolamina/envenenamento , Escopolamina/urina , Detecção do Abuso de Substâncias/métodos , Detecção do Abuso de Substâncias/normas , Adulto Jovem
2.
Clin Toxicol (Phila) ; 56(2): 101-107, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28703024

RESUMO

BACKGROUND: Physostigmine has long been recognized as an antidote to reverse anticholinergic delirium. However, its effectiveness, safety profile, and dosing have been disputed. OBJECTIVES: To describe effectiveness, adverse events, and dosing associated with the use of physostigmine to reverse anticholinergic delirium. METHODS: A retrospective cohort study of hospitalized patients reported to a regional poison center system between 2003 and 2012 who received physostigmine to reverse an anticholinergic toxidrome. Data extraction of a priori defined variables were recorded with concurrence of investigators. The cases were stratified by the primary ingestant as the presumed causative agent and associations for response were performed using odds ratios (ORs), 95% confidence intervals (CI's), and p values. RESULTS: Of the 1422 cases identified, 191 met the inclusion criteria. Patients exposed to non-diphenhydramine antihistamines (n = 14), antipsychotics (n = 4), and tricyclic antidepressants (n = 3) had 100% response to physostigmine, whereas anticholinergic plants (n = 46/67; 68.7%, OR: 0.70; CI: 0.36-1.35), diphenhydramine (n = 43/56; 64.2%, OR: 1.30; CI: 0.63-2.68), and combination products (n = 8/10; 80%, OR: 1.48; CI: 0.30-7.24) had partial response rates. Of the included patients, 142 (74.3%) were treated with physostigmine alone, and 16 (8.4%) of these patients were discharged directly from the emergency department (ED). DISCUSSION: Most patients, 182 (95.3%), had no documented adverse effects. Four patients (2.1%) experienced emesis, two experienced QTc prolongation (1.0%), and two experienced seizures (1.0%). There was a single fatality 6 h after physostigmine administration. Average initial total doses of physostigmine ranged from 1.0 to 1.75 mg. Most patients were admitted to the ICU (n = 110; 57.6%), however, 36 (18.8%) patients were discharged directly from the ED. CONCLUSIONS: In this retrospective cohort study, physostigmine administration to reverse anticholinergic delirium had a good safety profile, and often improved or resolved anticholinergic delirium when administered in doses less than 2 mg.


Assuntos
Antídotos/efeitos adversos , Antídotos/uso terapêutico , Antagonistas Colinérgicos/envenenamento , Delírio/induzido quimicamente , Delírio/tratamento farmacológico , Fisostigmina/efeitos adversos , Fisostigmina/uso terapêutico , Inibidores da Colinesterase/uso terapêutico , Humanos , Estudos Retrospectivos
3.
J Emerg Med ; 53(4): 520-523, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28756934

RESUMO

BACKGROUND: Scopolamine is a potent anticholinergic compound used commonly for the prevention of postoperative nausea and vomiting. Scopolamine can cause atypical anticholinergic syndromes due to its prominent central antimuscarinic effects. CASE REPORT: A 47-year-old female presented to the emergency department (ED) 20 h after hospital discharge for a right-knee meniscectomy, with altered mental status (AMS) and dystonic extremity movements that began 12 h after her procedure. Her vital signs were normal and physical examination revealed mydriasis, visual hallucinations, hyperreflexia, and dystonic movements. Laboratory data, lumbar puncture, and computed tomography were unrevealing. The sustained AMS prompted a re-evaluation that revealed urinary overflow with 500 mL of retained urine discovered on ultrasound and a scopolamine patch hidden behind her ear. Her mental status improved shortly after patch removal and physostigmine, with complete resolution after 24 h with discharge diagnosis of scopolamine-induced anticholinergic toxicity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although therapeutically dosed scopolamine transdermal patches rarely cause complications, incomplete toxidromes can be insidiously common in polypharmacy settings. Providers should thoroughly evaluate the skin of intoxicated patients for additional adherent medications that may result in a delay in ED diagnosis and curative therapies. Our case, as well as rare case reports of therapeutic scopolamine-induced anticholinergic toxicity, demonstrates that peripheral anticholinergic effects, such as tachycardia, dry mucous membranes, and hyperpyrexia are often not present, and incremental doses of physostigmine may be required to reverse scopolamine's long duration of action. This further complicates identification of the anticholinergic toxidrome and diagnosis.


Assuntos
Síndrome Anticolinérgica/diagnóstico , Antagonistas Colinérgicos/envenenamento , Síndrome Anticolinérgica/etiologia , Antagonistas Colinérgicos/uso terapêutico , Distonia/etiologia , Serviço Hospitalar de Emergência/organização & administração , Feminino , Alucinações/etiologia , Humanos , Meniscectomia/efeitos adversos , Meniscectomia/normas , Pessoa de Meia-Idade , Midríase/etiologia , Período Pós-Operatório , Escopolamina/envenenamento , Escopolamina/uso terapêutico , Adesivo Transdérmico
5.
Clin Toxicol (Phila) ; 55(5): 364-365, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28421841

RESUMO

A 13-year-old female was presented to the emergency department following an intentional ingestion. The patient developed significant toxicity including multiple, discreet tonic-clonic seizures. Despite appropriate resuscitation and antidotal management, the patient's symptoms persisted for more than 36 hours post-ingestion. An upright abdominal radiograph was performed revealing a radiopacity suggesting a pharmacobezoar. An esophagogastroduodenoscopy was performed with successful removal of a tennis ball-sized pharmacobezoar. The patient's symptoms subsequently subsided and she recovered fully with no neurologic deficits. Diphenhydramine has not been previously identified as a medication likely to form a pharmacobezoar and has not been shown to be radiopaque. Though bezoar formation is a rare clinical scenario, it is one that toxicologists must consider in patients with clinical courses that persist far beyond expected based on known toxicokinetic principles.


Assuntos
Bezoares/diagnóstico por imagem , Bezoares/terapia , Antagonistas Colinérgicos/envenenamento , Difenidramina/envenenamento , Adolescente , Overdose de Drogas/terapia , Serviço Hospitalar de Emergência , Endoscopia do Sistema Digestório , Feminino , Humanos , Convulsões/diagnóstico por imagem , Convulsões/terapia , Resultado do Tratamento
6.
Forensic Sci Int ; 274: 79-82, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28237441

RESUMO

The use of scopolamine as an incapacitating drug, in sexual crimes and robberies, has been known for many decades. However, blood concentrations and doses of scopolamine in those cases are largely unknown. Here we present the toxicological results of one fatal and two non-fatal cases in a series of scopolamine-facilitated robberies. In the fatal case, the concentration of scopolamine in heart blood was 0.30mg/L, about 3000 times higher than the average therapeutic level of 0.0001mg/L (for one dermal patch). In femoral blood, the concentration of scopolamine was much lower (0.0048mg/L), but still 50 times higher than therapeutic levels. The scopolamine concentration in the stomach was very high (20mg/kg) as compared to the heart blood and femoral blood, which explains the very high concentration in heart blood by postmortem leakage from the stomach. In the non-fatal case, the scopolamine concentration in serum, obtained 23h after the incident, was 0.00035mg/L. The estimated concentration of scopolamine at the time of the incident is 0.0035mg/L. In the other non-fatal case, scopolamine was detected in urine and in hair.


Assuntos
Antagonistas Colinérgicos/efeitos adversos , Antagonistas Colinérgicos/envenenamento , Escopolamina/efeitos adversos , Escopolamina/envenenamento , Roubo , Antagonistas Colinérgicos/análise , Conteúdo Gastrointestinal/química , Cabelo/química , Humanos , Masculino , Pessoa de Meia-Idade , Mudanças Depois da Morte , Escopolamina/análise
8.
Toxins (Basel) ; 8(3)2016 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-26999208

RESUMO

In the present review, the main objective was to report the incidence and causes of herbal medicines induced anticholinergic poisoning in Hong Kong during 1989-2012 and to emphasize the importance of pharmacovigilance, investigations and preventive measures. Relevant papers, official figures and unpublished data were obtained from Medline search, the Department of Health and the Drug and Poisons Information Bureau. In the New Territories East (where ~20% of the Hong Kong population lived), the incidence of herbal medicines induced anticholinergic poisoning during 1989-1993 was 0.09 per 100,000 population. There were no confirmed cases during 1994-1996. In the whole of Hong Kong, the incidence during 2000-June 2005 was 0.03 per 100,000 population. Contamination of Rhizoma Atractylodis (50%) and erroneous substitution (42%) were the main causes. The incidence during 2008-2012 was 0.06 per 100,000 population. Contamination of non-toxic herbs (50%) and erroneous substitution (41%) were the main causes. In Hong Kong, contamination of non-toxic herbs by tropane alkaloids and substitution of Flos Campsis by toxic Flos Daturae Metelis were the predominant causes of herbal medicines induced anticholinergic poisoning. Systematic studies along the supply chain are necessary to identify the likely sources of contamination. If erroneous substitution of Flos Campsis by Flos Daturae Metelis could be prevented, 40% of herbal medicines induced anticholinergic poisoning would not have occurred. Regular inspection of the retailer, continuing education for the staff in the herbal trade and repeated publicity measures will also be required. Pharmacovigilance of herbal medicines should help determine the incidence and causes of adverse reactions and monitor the effectiveness of preventive measures.


Assuntos
Antagonistas Colinérgicos/envenenamento , Fitoterapia/efeitos adversos , Plantas Medicinais/efeitos adversos , Hong Kong/epidemiologia , Humanos
9.
Br J Clin Pharmacol ; 81(3): 516-24, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26589572

RESUMO

The spectrum of anticholinergic delirium is a common complication following drug overdose. Patients with severe toxicity can have significant distress and behavioural problems that often require pharmacological management. Cholinesterase inhibitors, such as physostigmine, are effective but widespread use has been limited by concerns about safety, optimal dosing and variable supply. Case series support efficacy in reversal of anticholinergic delirium. However doses vary widely and higher doses commonly lead to cholinergic toxicity. Seizures are reported in up to 2.5% of patients and occasional cardiotoxic effects are also recorded. This article reviews the serendipitous path whereby physostigmine evolved into the preferred anticholinesterase antidote largely without any research to indicate the optimal dosing strategy. Adverse events observed in case series should be considered in the context of pharmacokinetic/pharmacodynamic studies of physostigmine which suggest a much longer latency before the maximal increase in brain acetylcholine than had been previously assumed. This would favour protocols that use lower doses and longer re-dosing intervals. We propose based on the evidence reviewed that the use of cholinesterase inhibitors should be considered in anticholinergic delirium that has not responded to non-pharmacological delirium management. The optimal risk/benefit would be with a titrated dose of 0.5 to 1 mg physostigmine (0.01-0.02 mg kg(-1) in children) with a minimum delay of 10-15 min before re-dosing. Slower onset and longer acting agents such as rivastigmine would also be logical but more research is needed to guide the appropriate dose in this setting.


Assuntos
Antídotos/uso terapêutico , Antagonistas Colinérgicos/envenenamento , Delírio/tratamento farmacológico , Overdose de Drogas/tratamento farmacológico , Antídotos/efeitos adversos , Inibidores da Colinesterase/efeitos adversos , Inibidores da Colinesterase/uso terapêutico , Delírio/induzido quimicamente , Humanos , Fisostigmina/efeitos adversos , Fisostigmina/uso terapêutico
12.
J Med Toxicol ; 11(2): 179-84, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25510306

RESUMO

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.


Assuntos
Antídotos/uso terapêutico , Antagonistas Colinérgicos/envenenamento , Fisostigmina/uso terapêutico , Envenenamento/tratamento farmacológico , Antipsicóticos/uso terapêutico , Benzodiazepinas/uso terapêutico , Uso de Medicamentos , Humanos , Envenenamento/epidemiologia , Sistema de Registros , Estudos Retrospectivos , Estados Unidos/epidemiologia
13.
Turk J Pediatr ; 56(3): 313-5, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25341608

RESUMO

Datura stramonium (DS) is a hallucinogenic plant that can produce anticholinergic toxicity because of its significant concentrations of toxic alkaloids, such as atropine, hyoscyamine, and scopolamine. DS grows in both rural and urban areas in Turkey. Clinical findings of toxicity are similar to those of atropine toxicity. DS abuse is common among adolescents because of its hallucinatory effects. However, accidental DS poisoning from contaminated food is very rare. Accidental poisonings are commonly seen among children. Children are more prone to the toxic effects of atropine; ingestion of even a small amount can cause serious central nervous system symptoms. Treatment is supportive; antidote treatment is given rarely. An eight-year-old male with accidental DS poisoning who presented to the Pediatric Emergency Department with aggression, agitation, delirium, and visual hallucinations is reported.


Assuntos
Antagonistas Colinérgicos/envenenamento , Datura stramonium/envenenamento , Alucinações/induzido quimicamente , Alucinógenos/envenenamento , Transtornos Relacionados ao Uso de Substâncias/etiologia , Adolescente , Criança , Transtornos da Consciência/induzido quimicamente , Transtornos da Consciência/diagnóstico , Alucinações/diagnóstico , Humanos , Masculino , Agitação Psicomotora/diagnóstico , Agitação Psicomotora/etiologia , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Turquia
14.
J Med Toxicol ; 10(4): 406-10, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24943229

RESUMO

INTRODUCTION: We report the case of an adolescent with anticholinergic toxidrome from diphenhydramine overdose, whose symptoms were treated with a novel application of dexmedetomidine. CASE REPORT: A 13-year-old female developed an anticholinergic toxidrome after intentionally ingesting 9.5 mg/kg of diphenhydramine. Despite routine supportive therapies, to include appropriate doses of lorazepam, she continued to have significant agitation, psychosis, and hallucinations. A dexmedetomidine infusion was started to aid in the treatment of her agitation and psychosis with marked improvement of her symptoms. DISCUSSION: Using dexmedetomidine for the treatment of anticholinergic toxidrome has not been previously described in the literature, but there are multiple reports of its use in alcohol withdrawal syndrome. We suggest that adding dexmedetomidine as an adjunctive agent in the therapy of anticholinergic toxidrome may relieve the symptoms of agitation, psychosis, tachycardia, and hypertension, without the attendant risk of respiratory depression associated with high doses of benzodiazepines.


Assuntos
Antagonistas Colinérgicos/envenenamento , Dexmedetomidina/uso terapêutico , Difenidramina/envenenamento , Adolescente , Overdose de Drogas , Feminino , Humanos
15.
J Forensic Sci ; 59(6): 1675-8, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24697166

RESUMO

A woman was found unresponsive with an empty bottle of Cogentin(®) prescribed to another. Admitted to an area hospital, her condition steadily declined until death 29 h after admission. Following toxicological screening on hospital (admission) whole blood, the only significant compound detected was benztropine. Benztropine was confirmed at 0.28 mg/L - the highest antemortem blood concentration recorded in a case of toxicity or fatality uniquely associated with benztropine. A second serum antemortem specimen showed a benztropine concentration of 0.19 mg/L. Despite over 24 h in the hospital, benztropine was also found in the postmortem specimens collected at autopsy. Peripheral blood, central blood, liver, and gastric concentrations were 0.47 mg/L, 0.36 mg/L, 9.6 mg/kg, and 44 mg, respectively. These results indicate that benztropine exhibited a potential difference between whole-blood and serum (plasma) concentrations. Additionally, in consideration of literature data, benztropine was found indicative of a compound prone to at least some postmortem redistribution.


Assuntos
Benzotropina/envenenamento , Antagonistas Colinérgicos/envenenamento , Suicídio , Benzotropina/análise , Antagonistas Colinérgicos/análise , Feminino , Conteúdo Gastrointestinal/química , Humanos , Fígado/química , Pessoa de Meia-Idade
16.
Gen Hosp Psychiatry ; 35(6): 682.e5-6, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23906840

RESUMO

Cannabis in its various forms has been known since time immemorial, the use of which has been rising steadily in India. 'Bad trips' have been documented after cannabis use, manifestations ranging from vague anxiety and fear to profoundly disturbing states of terror and psychosis. Cannabis is known to affect various neurotransmitters, but 'bad trip' due to its anticholinergic effect has never been described in literature to the best of author's knowledge. Hereby, the author describes a case of a young adult male experiencing profound anticholinergic effects after being exposed for the first time in his life to bhang, a local oral preparation of cannabis.


Assuntos
Acatisia Induzida por Medicamentos/etiologia , Ansiedade/induzido quimicamente , Cannabis/envenenamento , Antagonistas Colinérgicos/envenenamento , Taquicardia/induzido quimicamente , Retenção Urinária/induzido quimicamente , Adolescente , Humanos , Masculino , Xerostomia/induzido quimicamente
17.
Emerg Med Australas ; 25(3): 268-70, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23759049

RESUMO

A male landscaper presented with an acute confusional state following intentional ingestion of Duboisia myoporoides. With supportive care, he made an uneventful recovery after 24 h. Clinical features, investigation and management of Duboisia poisoning are discussed.


Assuntos
Antagonistas Colinérgicos/envenenamento , Delírio/induzido quimicamente , Duboisia/envenenamento , Folhas de Planta/envenenamento , Delírio/etiologia , Delírio/terapia , Ingestão de Alimentos , Humanos , Masculino , Adulto Jovem
20.
Hong Kong Med J ; 19(1): 38-41, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23378353

RESUMO

OBJECTIVE: To study the epidemiology, causes, and clinical course of Chinese herbal medicine-induced anticholinergic poisoning in Hong Kong. DESIGN: Case series. SETTING: Hong Kong. PATIENTS: All case histories of Chinese herbal medicine-induced anticholinergic poisoning (with laboratory confirmation) recorded by the Hong Kong Poison Information Centre over a 93-month period were accessed for analysis. RESULTS: During the relevant period, 22 clusters of Chinese herbal medicine-induced anticholinergic poisoning involving 32 patients were retrieved. The commonest clinical features were mydriasis (n=32, 100%) and confusion (n=24, 75%). No gastro-intestinal decontamination was performed. None of these patients underwent intubation, defibrillation, cardioversion, pacing, fluid resuscitation, inotropic support or dialysis. Of the 32 patients, 17 (53%) were treated with physostigmine because of confusion, three of whom had previously received intravenous benzodiazepines. No patient could be effectively treated with benzodiazepines alone. There was no mortality, and all the patients were discharged within 3 days. None of them re-attended the emergency department within 1 week of discharge. The commonest cause was the substitution of flos campsis (Campsis grandiflora) by the flower of the Datura species (7 clusters [32%] in 10 patients). CONCLUSION: Mydriasis and confusion were the commonest clinical features of Chinese herbal medicine-induced anticholinergic poisoning in Hong Kong. Physostigmine was frequently used in the treatment; benzodiazepines appeared ineffective. The commonest cause was the substitution of flos campsis (Campsis grandiflora) by the flower of the Datura species.


Assuntos
Benzodiazepinas/uso terapêutico , Antagonistas Colinérgicos/envenenamento , Medicamentos de Ervas Chinesas/envenenamento , Fisostigmina/uso terapêutico , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Inibidores da Colinesterase/uso terapêutico , Análise por Conglomerados , Feminino , Hong Kong/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Centros de Controle de Intoxicações , Resultado do Tratamento , Adulto Jovem
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