Anticholinergic Toxicity

Clinical Presentation

The American Academy of Pediatrics notes that anticholinergic toxicity is characterized by delirium, hot and dry skin with erythema, mydriasis, tachycardia, mild hyperthermia, tachypnea, and decreased or absent bowel sounds 1
The clinical presentation includes cardiovascular effects such as tachycardia and mild hypertension 1
Peripheral effects include hot and dry skin, mydriasis, and decreased or absent bowel sounds 1
Respiratory effects include tachypnea 1
The skin is dry and erythematous, distinguishing it from sympathomimetic toxicity which presents with diaphoresis 1

The American Academy of Pediatrics recommends discontinuing the precipitating agent, supportive care with IV fluids, benzodiazepines for agitation, and physostigmine for severe toxicity with significant CNS or life-threatening peripheral effects 1
The treatment includes initial stabilization with assurance of airway, breathing, and circulation, and administration of benzodiazepines for agitation and convulsions 2
Physostigmine is indicated for severe anticholinergic toxicity with significant CNS or life-threatening peripheral effects, with a dosage of 1-2 mg IV in adults and 0.02 mg/kg IV in pediatrics 2
Contraindications for physostigmine include cardiovascular disease, asthma, gangrene, diabetes, or mechanical obstruction of the intestine or urinary tract 2

The management of complications includes measures for hyperthermia, such as external cooling, and treatment of QRS prolongation or dysrhythmias with sodium bicarbonate 1, 2
The American Society of Anesthesiologists recommends avoiding succinylcholine in patients with anticholinergic crisis as it may cause prolonged paralysis 3, 2