ANTIHISTAMINES - rEMERGs

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Nitroprusside or phentolamine for hypertensive emergenciesHypertensive + Bradycardic: note that atropine may not be a good idea b/c bradycardia is aresponse to the hypertension from the pure alpha effect; atropine may result in massive increase inBP if the bradycardia is a reflexic responseANTICHOLINERGICSINTRODUCTION Belladonna alkaloids = prototypical anticholinergics; atropine, scopolamine, hysocyamine Jimson week: contains scopolamineCOMMON CAUSES OF ANTICHOLINERGIC SYNROME Plants‣ Jisonweed‣ Angel’s tumptt‣ Jasmine‣ Mandrake‣ Deadly nightshade‣ Etc Belladona Alkaloids‣ Atropine‣ Scopolamine‣ Homatropine‣ Cyclopentolate‣ Tropicamide‣ Ipratropium Antihistamines‣ Benadryl‣ Atarax‣ Gravol‣ Dramamine‣ Antivert‣ Brompheniramine Phenothiazines Aniparkinson agents‣ Cogentin‣ Artane‣ Kemadrin‣ EtcANTICHOLINERGIC EFFECTS AS PART OF TOXIDROME Flexeril Tegretol Amitriptyline Imipramine Doxepin Amoxapine
DesipramineNortripyltinMellarilSerentilThoraxineCompazineCOMMON OTC SLEEP AIDS Pyrilamin (Sominex) Diphenhydramine (Nytol, Benadryl) Cyclizine (Marezine)PRINCIPLES OF DISEASE Muscarinic effects Do not have nicotinic effects (paralysis, weakness, resp failure) b/c there is no blockage at theNMJ Muscarinic blockade‣ Tachycardia‣ Mydriasis‣ Absent bowel sounds‣ HOT and DRY SKIN (can’t sweat!) (sympathomimetic is wet)‣ Urinary retention‣ Decreased ability for visual accomodation‣ Dry mucous membranes Central effects‣ Seizures‣ Delirium‣ Coma‣ Agitation‣ Fever Delirium‣ Elderly patient with delirium‣ May be due to antiparkinsonian drugs, antipsychotic drugs, or TCAs‣ Common overlooked Fever‣ Can be afebrile or severe temperature elevation‣ Severe hyperthermia associated with cerebral edema, rhabdo, DIC‣ Requires aggressive sedation, coolingDDXSympathomimetic sweaty, anticholinergic dry (sympathomimetics can be dry if dehydrated)Seritonin syndrome has hypereflexia and increased tone, anticholinergics usually don’tThyroid storm, meningitis, encephalitis, etcMANAGMENT Agitation: benzos are drug of choice Hyperthermia: temps q1hr, ice to groin, fans, cooling blankets, bzd, intubation and paralysis Decontamination: activated charcoal; avoid sorbitol if there are no bowel sounds; MDAC may be aproblem b/c of decreases gut motility (enemas may help)
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