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Clin Toxicol (Phila). 2019 Jan;57(1):50-55. doi: 10.1080/15563650.2018.1485154. Epub 2018 Jun 29.

Physostigmine is superior to non-antidote therapy in the management of antimuscarinic delirium: a prospective study from a regional poison center.

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a Department of Emergency Medicine , United Hospital , Minneapolis , MN , USA.
b Minnesota Poison Control System , Minneapolis , MN , USA.
c Department of Entomology , University of Minnesota , Saint Paul , MN , USA.



Poison centers (PCs) frequently manage patients with antimuscarinic delirium. However, controversy surrounds the antidotal use of physostigmine for its treatment. The aim of this study was to prospectively investigate physostigmine versus non-antidote therapy for the management of antimuscarinic delirium in a single regional PC.


This was a prospective observational analysis of patients diagnosed with antimuscarinic delirium and treated in consultation with a regional PC. Certified Specialists in Poison Information (CSPIs) use a clinical guideline to recommend the use of physostigmine. Using a previously derived altered mental status score, we quantified the rate of delirium improvement with physostigmine compared to non-antidote therapy two hours after initial patient identification. We also recorded adverse events (defined a priori as bradycardia, vomiting, seizures) and resource utilization (intubation and physical restraint).


We identified 245 patients and included 154 in the analysis. The most common exposure classes were antihistamines (68%), analgesics (19%), and antipsychotics (19%). CSPIs recommended physostigmine in 81% (125) of cases and the treatment team administered it in 37% (57) of these. We observed delirium control in 79% of patients who received physostigmine versus 36% of those who did not. The odds of delirium control were six times greater for patients receiving physostigmine than for patients treated with non-antidote therapy (OR 6.6). Adverse events were rare and did not differ significantly between the groups. Physostigmine was not associated with changes in the incidence of intubation or restraint.


This study provides further evidence of both the safety and efficacy of physostigmine in the treatment of antimuscarinic delirium.


Physostigmine; anticholinergic toxidrome; antimuscarinic; delirium; poison center

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