It is my impression that our toxicology service and the local poison center have consulted on an increasing number of cases involving symptomatic exposure to diphenhydramine since the COVID-19 pandemic began last year. Diphenhydramine appears regularly on the system’s list of most common exposures about which poison centers are contacted. poison centers received nearly 20,000 calls about exposure to diphenhydramine as a single agent in 2019, the last year for which data are available. The National Poison Data System reported that U.S. This breakdown in the supply chain came at a particularly unfortunate time. In fact, they haven’t had physostigmine for months because of a nationwide shortage. Ten minutes later, the nurse tells you that the pharmacy received your order, but the hospital has no physostigmine on hand. This results in increased levels of acetylcholine in central synapses, overcoming the effects of competitive acetylcholine blockers such as diphenhydramine.įeeling secure in your diagnosis and treatment plan, you write an order for 1 mg physostigmine IV over five minutes and move to the next patient. Physostigmine reversibly inhibits acetylcholinesterase, the enzyme that breaks down acetylcholine. That antidote is physostigmine salicylate, a carbamate with a tertiary amine structure that allows it to cross the blood-brain barrier readily and reverse central antimuscarinic effects such as agitation and delirium. You let out a sigh of relief because a safe antidote is effective for just this situation. The patient had all the typical signs and symptoms: He was as hot as a hare, red as a beet, dry as a bone, blind as a bat (i.e., mydriatic), and mad as a hatter. This was a clear-cut case of the antimuscarinic toxidrome.
His father said he had no allergies, history of asthma, or other chronic medical problems. An electrocardiogram showed sinus tachycardia at a rate of 120 bpm but a normal QRS interval and no other abnormalities. He was mumbling incoherently, picking at his hospital gown, and apparently hallucinating. He was tachycardic with warm flushed skin, dry mucous membranes, dilated and minimally reactive pupils, and absent bowel sounds. Rivastigmine Steps in During Physostigmine ShortageĪ 17-year-old was brought in by his family after ingesting 40 to 50 diphenhydramine tablets. Procalcitonin: Risk Assessment in COVID-19 Bacterial Co-Infection.Current Procalcitonin Utilization and Publications.The Physician Grind EMN with Zahir Basrai, MD.EM Board Bombs with Blake Briggs, MD, and Iltifat Husain, MD.These simplified toxidromes should not take the place of clinical judgment. Exposure to multiple classes as well as patient specific variables can result in mixed or partial toxidromes. *NOTE: The toxidromes assume a single substance or class exposure. Tachypnea, hyperpnea, neuroglycopenia (low CSF glucose)Īspirin, oil of wintergreen, bismuth subsalicylateĪMS, hallucinations, delusions, agitation, psychosisĮcstasy, Molly, LSD, peyote, psilocybin-containing mushrooms, dextromethorphan, cannabinoids, phencyclidine Tachypnea, hyperpnea, AMS, confusion, seizures, acid-base disturbance *NOTE: a mixture of muscarinic and nicotinic effects can be seen throughout the clinical courseīenzodiazepines, barbiturates, alcohols, anticonvulsantsĪnxiety, CNS agitation, seizures, diaphoresis, delusions, psychosis, active bowel sounds, mydriasis that responds to lightĬocaine, amphetamines, synthetic (e.g. Organophosphate pesticides, carbamate pesticides, cholinergic mushrooms, nerve gas chemical warfare agents, pyridostigmine, neostigmine, physostigmine The information herein is intended for educational purposes and should not be used to supersede clinical judgement or toxicologic consultation.Īntihistamines, atropine, scopolamine, angel trumpet, jimson weed, cyclic antidepressants, antipsychotics There are multiple factors that affect a patient’s presentation and treatment options.
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