47 y/o M BIBEMS altered mental status (wife called EMS from out of country because husband hasn’t been heard from in 2 days) no history available from patient.  ? short lasting tonic-clonic activity noted on arrival.

Vitals: 101.7  128  140/91 19  96%   FS 143

PE remarkable for an agitated male, AOx1 not following basic commands. Laceration to forehead, Pupils dilated but equal and reactive. Tachycardic but regular rate; Lungs CTAB. Abdomen with decreased bowel sounds but SNT. Skin hot and dry. Neuro exam non-focal

EKG ST @ 137; Qtc 475; incomplete RBBB

Initial labs remarkable for WBC 19 (89% PMN); Lactate 6.2. Foley placed 1200 cc urine voided with UA WNL. CXR and Head CT WNL

Just in time the cousin arrives with an empty bottle of Benadryl (just as the patient was being turned to set up for an LP!). This patient has an Anticholinergic picture of Bendaryl OD.


Anticholinergic OD: Red as beet; Dry as a bone; Hot as a hare; Blind as a bat; Mad as a Hatter (seizures as with this patient possible); Full as a flask . tachycardia (earliest sign of OD), decreased Bowel sounds

Rx: ABCs of course!!   Charcoal can be given within first 2 hours of ingestion if patient can tolerate it; Sodium Bicarb for QTc and QRS prolongation (given in this case in anticipation of continued absorption and lengthening of already prolonged QTc); Benzo’s for seizures and agitation, Physostigmine.

Physostigmine– once part of the “coma cocktail” for AMS now not often used.

A carbamate acetylcholinesterase inhibitor that binds reversibly to inhibit acetylcholinesterase increasing amounts of acetylcholine to overcome anticholinergic blockade.

Should not be given if TCA OD is suspected (more sedated than agitated anticholinergic picture) especially if patient has wide QRS cause can lead to asystole

Superior to Benzos for the AMS/agitation of anticholinergic OD

Can be used diagnostically if unclear picture as administration of physostigmine in AC OD should result in improvement of clinical picture. Repeat dosing can be done every 20-30 minutes for continued agitation/delirium.


Reminders for the oral boards:  altered patients need all 6 vitals HR, BP, RR, O2 Sat, Temp and FS. Always order Tylenol for patients with fevers and tetanus for patient with lacerations.

Thank you Raashee for interesting morning report!