The 14 mg of physostigmine administered is much higher than typical dosing. It is likely the physostigmine prevented intubation. Atropine eye drops can be dangerous, and physostigmine should be considered in treatment. Atropine, or hyoscyamine, is an alkaloid used commonly for its antimuscarinic properties.
It can be administered by various routes, including the eye drop formulation of atropine sulfate, used to induce cycloplegia and mydriasis. These phenomena have been described even with attempted therapeutic ophthalmic use. Physostigmine is a carbamate that acts by reversibly inhibiting acetylcholinesterase. Unlike quaternary amine acetylcholinesterase inhibitors such as neostigmine that treat peripheral manifestations of the antimuscarinic toxidrome, physostigmine is a tertiary amine, and thus is able to cross the blood-brain barrier to treat both central eg, agitation and delirium and peripheral eg, tachycardia antimuscarinic manifestations.
Its popularity grew in the s and s as a general antidote and diagnostic tool for altered mental status. However, recent literature has tempered some of the concern about the deleterious effects of physostigmine, and its use has again become more frequent.
We describe an adult male with a massive ingestion of atropine eye drops treated successfully with 11 mg IV physostigmine in the emergency department. Successful treatment in this case is defined as improvement of altered mental status and avoidance of need for intubation. A year-old male presented to an urgent care center, where he collapsed on arrival in the triage area, per providers in that department. He stated that he had emptied a full bottle of atropine eye drop solution into a glass of water and ingested it in an attempt to harm himself.
On initial presentation, he had altered mental status with waxing and waning coherence, and when awake, he was very combative. He was also tachycardic with a heart rate HR of beats per minute. A fingerstick glucose was normal. He was given 2 mg IV lorazepam, 4 mg IV ondansetron, 50 gm oral activated charcoal, and quickly transferred to a larger local hospital for further care.
In the emergency department at the accepting facility, the patient continued to have altered mental status, varying between severe sedation and uncontrolled agitation. He had flushed skin, dry oral mucosa, nonreactive mydriasis, and a rectal temperature of He showed no signs of trauma and had a nonfocal neurologic examination other than the gross altered mental status.
The remainder of his physical exam was unremarkable. Electrocardiogram revealed sinus tachycardia and no interval or segment abnormalities.
Due to the intermittent somnolence and uncontrolled agitation, the emergency physicians at the accepting facility were concerned for the patient's ability to protect his airway enough to maintain oxygenation and ventilation.
This, in combination with the recently administered charcoal and the possibility of emesis with subsequent aspiration, was enough cause for them to move towards rapid sequence induction RSI and endotracheal intubation. Atropine causes the muscles in your eye to become relaxed.
This widens dilates your pupil so that it will not respond to light. Atropine ophthalmic for the eye is used to dilate your pupils when you have an inflammatory condition or in postsurgery situations in which this effect may be helpful.
Atropine ophthalmic is also used in people with a condition called amblyopia sometimes called "lazy eye". Atropine ophthalmic can be placed into the stronger eye to temporarily blur the vision in that eye.
This helps strengthen the weaker eye because the brain will force that eye to work harder to focus. Atropine ophthalmic may also be used for purposes other than those listed in this medication guide. It is not known whether this medicine will harm an unborn baby. Tell your doctor if you are pregnant.
Atropine ophthalmic can pass into breast milk and may harm a nursing baby. Tell your doctor if you are breast-feeding a baby. Follow all directions on your prescription label. Do not use this medicine in larger or smaller amounts or for longer than recommended. Do not use the eye drops if the liquid has changed colors or has particles in it. Call your pharmacist for new medicine. Do not touch the tip of the eye dropper or ointment tube or place it directly on your eye.
A contaminated dropper or tube tip can infect your eye, which could lead to serious vision problems. Store at room temperature away from moisture and heat. The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine. If you miss a dose of this medicine, take it as soon as possible.
However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses. Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light.
Keep from freezing. It is very important that your doctor check your progress at regular visits to make sure that this medicine is working properly and to check for unwanted effects. Diarrhea usually stops 2 days after treatment with this medicine. If your symptoms do not improve or if they get worse within 10 days of treatment, check with your doctor. This medicine may cause serious stomach or bowel problems eg, toxic megacolon. This is more likely if you also have ulcerative colitis.
Check with your doctor right away if you have bloating, constipation, loss of appetite, nausea, vomiting, or stomach pain. Check with your doctor if you have dizziness, fast, shallow breathing, a fast, weak heartbeat, headache, muscle cramps, pale, clammy skin, thirst, extremely high fever or body temperature, decrease in urine volume, decrease in frequency of urination, difficulty in passing urine, painful urination, dry skin and mouth.
This may be signs of condition called atropinism. Check with your doctor before using this medicine with alcohol or other medicines that affect the central nervous system CNS. The use of alcohol or other medicines that affect the CNS with diphenoxylate and atropine combination may worsen the side effects of this medicine, such as dizziness, poor concentration, drowsiness, unusual dreams, and trouble with sleeping. Some examples of medicines that affect the CNS are antihistamines or medicine for allergies or colds, sedatives, tranquilizers, or sleeping medicines, medicine for depression, medicine for anxiety, prescription pain medicine or narcotics, medicine for attention deficit and hyperactivity disorder, medicine for seizures or barbiturates, muscle relaxants, or anesthetics, including some dental anesthetics.
If you think you or anyone else may have taken an overdose of this medicine, get emergency help at once. Taking an overdose of this medicine may lead to unconsciousness and possibly death.
Fluoxetine is a selective serotonin reuptake inhibitor that can be used used for multiple mental health conditions. When used this way, a person may experience such effects as an increase in energy, talkativeness, and mood elevation. Fluoxetine abuse can produce many psychologic and physiologic responses such as depression, suicidal ideation, hallucinations, anxiety, and even paranoia. If abused often, it can become addictive.
Second-generation antipsychotics, such as quetiapine and olanzapine, are often abuse for their sedative and anxiolytic effects. Oftentimes, they are even combined with cocaine or heroin to get a euphoric and hallucinogenic effect, or combined with opiates and benzodiazepines for an enhanced sedative and calming effect.
The usual dosage range of quetiapine is from mg daily, while oral abuse occurs at consuming mg at a time. Comparatively, olanzapine is usually dosed from mg daily when taken by mouth; abuse and sedative effects can be witnessed at mg, or tablets, per day.
Mild-to-moderate symptoms of antipsychotic abuse include dry mouth, constipation, and somnolence. In higher concentrations, QT prolongation, seizure, delirium, arrhythmias, and sinus tachycardia can occur.
Death is rare and usually due to polysubstance abuse. Illicit use of both has been reported, but more often with quetiapine. Abuse of these agents, once only common in the general public, has increased in the correctional facility population.
Its mechanism of action is to prolong transit time, increase bulk density, and improve stool frequency and consistency. It also is an opioid-receptor agonist. The OTC dose of loperamide is 8 mg per day, whereas the prescription dosage is 16 mg daily.
However, at supertherapeutic doses approximately greater than a gram , it has been reported to cross the BBB and cause euphoria and other opioid-like effects.
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