Emergency Room Management of Psilocybin (Magic Mushroom) Overdose
The emergency room management of psilocybin (magic mushroom) overdose should focus on supportive care, as there is no specific antidote for psilocybin toxicity, with monitoring of vital signs and management of psychological symptoms being the cornerstones of treatment.
Initial Assessment and Stabilization
- Assess airway, breathing, and circulation
- Obtain vital signs including temperature (hyperthermia may occur)
- Perform focused neurological examination
- Check for signs of the psilocybin toxidrome:
- Visual and auditory hallucinations
- Altered mental status
- Mydriasis (dilated pupils)
- Tachycardia
- Hypertension
- Nausea and vomiting
- Diaphoresis (excessive sweating)
Management Approach
Supportive Care
- Provide a calm, quiet environment with minimal stimulation to reduce anxiety and agitation
- Monitor vital signs continuously
- Provide IV fluids if needed for dehydration
- Treat hyperthermia if present with cooling measures
Psychological Support
- Reassurance and verbal de-escalation for agitated patients
- Avoid physical restraints if possible as they may worsen psychological distress
- Consider psychiatric consultation for severe psychological reactions
Pharmacological Interventions
- For severe agitation or anxiety:
- Benzodiazepines are first-line therapy
- Consider lorazepam 1-2 mg IV/IM or diazepam 5-10 mg IV/IM
- Titrate to effect for symptom control
Gastrointestinal Decontamination
- Activated charcoal (1 g/kg orally) may be considered if presentation is within 1-2 hours of ingestion 1
- Not recommended if:
- Patient has altered mental status without airway protection
- Presentation is delayed (>2 hours after ingestion)
Special Considerations
Polysubstance Ingestion
- Consider the possibility of co-ingestion with other substances
- Obtain toxicology screening if available, but don't delay treatment waiting for results
Complications Management
- For persistent vomiting: antiemetics (ondansetron 4-8 mg IV)
- For severe myalgias: supportive care and hydration 2
- For rare cases of methemoglobinemia: consider methylene blue if symptomatic and levels >30% 2
Disposition
Most patients can be discharged after 6-8 hours of observation if symptoms are resolving 3
Criteria for discharge:
- Resolution of hallucinations and altered mental status
- Stable vital signs
- Ability to tolerate oral intake
- Safe discharge plan
Consider admission for:
- Persistent severe symptoms
- Significant psychiatric symptoms
- Evidence of rhabdomyolysis or other complications
- Suspected co-ingestion of other substances
Pitfalls and Caveats
- Psilocybin toxicity can be difficult to diagnose as standard urine drug screens do not detect psilocybin 4
- Symptoms typically resolve within 6 hours but may last up to 12 hours in some cases 3
- Unlike Amanita phalloides mushrooms, psilocybin mushrooms do not cause hepatotoxicity, so penicillin G and silymarin treatments are not indicated 1
- Avoid administering haloperidol or other typical antipsychotics as first-line agents as they may lower seizure threshold and worsen outcomes
Remember that while psilocybin mushroom ingestion can cause significant psychological distress, it rarely causes life-threatening physical symptoms when ingested alone. The focus should be on supportive care and management of psychological symptoms until the effects naturally subside.