From the Guidelines
Atropine psychosis treatment involves immediate discontinuation of the anticholinergic agent and supportive care, with physostigmine being the specific antidote, administered at 1-2 mg IV slowly over 5 minutes for adults (0.02 mg/kg for children). The treatment approach is based on the principles of managing anticholinergic poisoning, which includes removing the precipitating agent and providing supportive care 1. Physostigmine works by inhibiting acetylcholinesterase, increasing acetylcholine levels to counteract anticholinergic effects.
Key Considerations
- Discontinuation of the anticholinergic agent is crucial in managing atropine psychosis 1.
- Supportive care includes treatment of agitation, management of autonomic instability, and monitoring of vital signs.
- Physostigmine should be used cautiously in patients with cardiac conduction abnormalities or asthma.
- Benzodiazepines like lorazepam (1-2 mg IV) or diazepam (5-10 mg IV) may be used to manage agitation.
- Patients require continuous cardiac monitoring, temperature regulation, and a quiet, controlled environment to minimize sensory stimulation.
Treatment Details
- Physostigmine dosage: 1-2 mg IV slowly over 5 minutes for adults (0.02 mg/kg for children), which can be repeated after 10-30 minutes if symptoms persist.
- IV fluids help with dehydration and elimination of the drug.
- Most cases resolve within 24-48 hours as the anticholinergic agent is metabolized and excreted, though longer observation may be needed for sustained-release formulations or large overdoses.
From the FDA Drug Label
10 OVERDOSAGE ... Toxic doses lead to restlessness and excitement, hallucinations, delirium and coma. ... In the event of toxic overdosage, a short acting barbiturate or diazepam may be given as needed to control marked excitement and convulsions ... Physostigmine, given as an atropine antidote by slow intravenous injection of 1 to 4 mg (0. 5 to 1 mg in pediatric populations), rapidly abolishes delirium and coma caused by large doses of atropine.
- Treatment for atropine psychosis involves administering a short-acting barbiturate or diazepam to control marked excitement and convulsions.
- Physostigmine is given as an atropine antidote to rapidly abolish delirium and coma caused by large doses of atropine, with doses of 1 to 4 mg (or 0.5 to 1 mg in pediatric populations) administered by slow intravenous injection 2.
From the Research
Treatment Options for Atropine Psychosis
- Physostigmine is considered the drug of choice for reversing the signs and symptoms of anticholinergic poisoning, including atropine psychosis 3, 4, 5, 6, 7.
- Benzodiazepines may be used if sedation is indicated, but their effectiveness in reversing delirium is limited compared to physostigmine 5, 6, 7.
- Phenothiazines should be avoided for sedation in anticholinergic poisoning due to their potential to exacerbate the condition 3.
Efficacy of Physostigmine
- Physostigmine has been shown to control agitation and reverse delirium in 96% and 87% of patients, respectively, with anticholinergic poisoning 5.
- Patients treated with physostigmine had a significantly lower incidence of complications and a shorter time to recovery compared to those treated with benzodiazepines 5.
- Physostigmine was more likely to be used in patients with primarily anticholinergic effects, and its use was associated with a lower rate of intubation 6.
Clinical Use of Physostigmine
- Despite its effectiveness, physostigmine is often underutilized and poorly understood in the clinical setting 7.
- Physostigmine can be used to treat severe anticholinergic delirium and prevent the need for intubation and mechanical ventilation 7.
- The use of physostigmine in anticholinergic toxicity is supported by studies demonstrating its safety and efficacy in reversing the toxidrome 4, 5, 6.