SESSION TITLE: Critical Care Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Anticholinergic toxicity is characterized by blurred vision, delirium, dry skin, flushing, hallucinations, ileus, mydriasis, myoclonus, psychosis, seizures, urinary retention and coma. Complications include hypertension, hyperthermia, and tachycardia. A well known cause of anticholinergic symptoms are from anti-histamines such as diphenhydramine and doxylamine, both of which are omnipresent in the billion dollar industry of over the counter cold medications.
CASE PRESENTATION: Our case is of a 20 year old male with a history of asthma who presented to the emergency department after being found altered with lethargy, slurring of speech, and picking at the air. He was completely alert and oriented the evening prior to presentation complaining of increased lethargy and viral-like symptoms (cough, congestion, and rhinorrhea) that had been present for over a week. At 4 am, his mother heard a loud crash in his room. When she went to see him he was lying face down in bed, confused, slurring his speech. EMS was called and his glucose was found to be 59, but there was no improvement in his symptoms after an amp of D50. Acetaminophen, salicylate, ammonia, and thyroid levels were all within normal limits. A CBC, BMP, VBG, CT HEAD, chest x-ray, carboxyhemoglobin, urine toxicology and LP were checked all of which were non-actionable. EKG showed sinus tachycardia with prolonged QTc to 536ms. Patient was also found to be hypertensive. After these investigations yielded no results, a more detailed physical and history were performed. Patient's mother stated that he was taking large amounts of OTC cold medications DayQuil and NyQuil as well as his usual sleep aid, Simply Sleep, all containing diphendhdramine/doxylamine. Closer physical examination revealed 6mm dilated pupils, flushing of his skin, and the previously mentioned altered mental status consistent with an anticholinergic toxicity, but also urinary incontinence and moist tongue. With the history and physical findings patient was given 2mg of physostigmine over 5 minutes and after became completely alert and oriented. He was monitored in ICU but didn't require further physostigmine administrations.
DISCUSSION: Anticholinergic delirium is known complication of the drugs like diphenhydramine which is not very commonly encountered especially in younger population. It is important to note that over the counter cough syrups have doxylamine which is a very potent antihistamine and anticholinergic. Combination of this with diphenhydramine produces a strong anticholinergic activity which caused the delirium in our patient.
CONCLUSIONS: This was a young patient who presented with a very common complaint due to very common medications. Despite this he underwent an extensive workup, when the life saving intervention was made based on a detailed history and physical.
Reference #1: Toxidromes. Holstege CP, Borek HA. Crit Care Clin. 2012 Oct;28(4):479-98. doi: 10.1016/j.ccc.2012.07.008. Epub 2012 Aug 27. Review.
DISCLOSURE: The following authors have nothing to disclose: Ricky Mehta, Dilpreet Kaur, Gaganjot Singh
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