Anticholinergic Toxidrome Diagnosis and Management

Clinical Presentation

The American Academy of Pediatrics suggests that anticholinergic toxidrome is characterized by dry mucous membranes, flushed skin, dilated pupils, tachycardia, hyperthermia, altered mental status with agitated delirium, and visual hallucinations 1, 2, 3
Dry mucous membranes and hot, dry, erythematous skin are pathognomonic for anticholinergic poisoning, according to the American Academy of Pediatrics 1, 2, 3
Mydriasis (dilated pupils) is characteristic of anticholinergic toxicity, as stated by the American Academy of Pediatrics 1, 2
Agitated delirium with visual hallucinations represents the "mad as a hatter" component of anticholinergic toxidrome, as described by the American Academy of Pediatrics 1, 3
Mild hyperthermia with tachycardia and hypertension fit the anticholinergic profile, according to the American Academy of Pediatrics 1, 2
Hypoactive or absent bowel sounds would be expected in anticholinergic poisoning, as suggested by the American Academy of Pediatrics 1, 2

The American Academy of Pediatrics recommends supportive care with continuous cardiorespiratory monitoring for patients with anticholinergic toxidrome 1, 2
Benzodiazepines are recommended for agitation (first-line treatment) in patients with anticholinergic toxidrome, according to the American Academy of Pediatrics 1, 2
Aggressive cooling measures are recommended for hyperthermia if temperature rises in patients with anticholinergic toxidrome, as stated by the American Academy of Pediatrics 1, 2
IV fluid resuscitation is recommended for hypotension if it develops in patients with anticholinergic toxidrome, according to the American Academy of Pediatrics 1, 2
Physostigmine is the specific antidote for severe anticholinergic toxicity and can produce dramatic reversal within minutes, but its use should be reserved for life-threatening complications, as recommended by the American Academy of Pediatrics 1, 2, 3
Activated charcoal may be considered if the patient can safely swallow or has a protected airway, as suggested by the American Heart Association 4

Serial ECGs are recommended to monitor for QRS widening (suggesting co-ingestion of tricyclic antidepressants) in patients with anticholinergic toxidrome, according to the American Academy of Pediatrics 1, 2
Core temperature monitoring is recommended for patients with anticholinergic toxidrome, as stated by the American Academy of Pediatrics 1, 2
Continuous cardiac monitoring is recommended for dysrhythmias in patients with anticholinergic toxidrome, according to the American Academy of Pediatrics 1, 2
Physical restraints are contraindicated in patients with anticholinergic toxidrome, as they may exacerbate hyperthermia and worsen lactic acidosis, as recommended by the American Academy of Pediatrics 1, 2