Pediatric emergency medicine trisk 3157 3157

history and clinical suspicion. Along similar lines, serum drug levels do not
predict the degree of anticholinergic symptoms.
GI decontamination with activated charcoal may be valuable beyond an hour
after anticholinergic poison ingestion because of the likelihood of extended drug
persistence in the gut lumen.
On the basis of presenting signs and symptoms, the patient may require
sedation and monitoring in an intensive care unit setting to provide ventilatory
support for coma, anticonvulsants for seizures, and antiarrhythmic drugs for
cardiac dysrhythmias. Adequate sedation may be achieved with titrated doses of
benzodiazepines. Physostigmine, a potent anticholinesterase, is a recognized
antidote for anticholinergic-induced mental status alterations and can be very
effective in the correct clinical setting; however, its use is controversial.
Physostigmine can produce bronchospasm, bradycardia, hypotension, and
seizures. It is therefore reserved for those who have normal EKGs (QRS duration
less than 100 ms) and life-threatening delirium. Most such patients will respond
to supportive care and benzodiazepines. The adult dose is 1 to 2 mg via slow IV
infusion over 5 minutes. The trial dose can be repeated in 10 to 15 minutes up to a
maximum of 4 mg. The pediatric dose is 0.5 mg IV administered slowly, with
repeat every 10 minutes up to a maximum of 2 mg. The smallest effective dose
may be repeated every 30 to 60 minutes if symptoms recur over 6 to 8 hours. The
muscarinic toxicity of physostigmine may be treated with IV atropine at one-half
the physostigmine dose given; physostigmine-related seizures may be treated
with benzodiazepines.

Central Nervous System Sedative-Hypnotics
Current Evidence
The sedative-hypnotics have tranquilizing, euphoriant effects that may be similar
to morphine. With all these agents—prescribed for this tranquilizing action—it is
difficult to draw the line between appropriate use, abuse, habituation, and
addiction. However, for all, tolerance is common and physical dependence
quickly develops. Therefore, their abuse potential is considered high. Many of

these agents, including glutethimide, meprobamate, methaqualone, and
barbiturates, are uncommonly available and have been replaced by the
benzodiazepines. Because they have retained some popularity and still make
periodic appearances on the streets, however, they should be included in
discussions of such drugs.
For all sedative-hypnotics, patterns of abuse vary, ranging from infrequent
sprees of intoxication to compulsive daily use. Introduction may be through street