Zhang Xiao Chi, Farrell Natalija, Haronian Thomas, Hack Jason
Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island.
Department of Pharmacy, Rhode Island Hospital, Providence, Rhode Island.
J Emerg Med. 2017 Oct;53(4):520-523. doi: 10.1016/j.jemermed.2017.05.003. Epub 2017 Jul 27.
Scopolamine is a potent anticholinergic compound used commonly for the prevention of postoperative nausea and vomiting. Scopolamine can cause atypical anticholinergic syndromes due to its prominent central antimuscarinic effects.
A 47-year-old female presented to the emergency department (ED) 20 h after hospital discharge for a right-knee meniscectomy, with altered mental status (AMS) and dystonic extremity movements that began 12 h after her procedure. Her vital signs were normal and physical examination revealed mydriasis, visual hallucinations, hyperreflexia, and dystonic movements. Laboratory data, lumbar puncture, and computed tomography were unrevealing. The sustained AMS prompted a re-evaluation that revealed urinary overflow with 500 mL of retained urine discovered on ultrasound and a scopolamine patch hidden behind her ear. Her mental status improved shortly after patch removal and physostigmine, with complete resolution after 24 h with discharge diagnosis of scopolamine-induced anticholinergic toxicity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although therapeutically dosed scopolamine transdermal patches rarely cause complications, incomplete toxidromes can be insidiously common in polypharmacy settings. Providers should thoroughly evaluate the skin of intoxicated patients for additional adherent medications that may result in a delay in ED diagnosis and curative therapies. Our case, as well as rare case reports of therapeutic scopolamine-induced anticholinergic toxicity, demonstrates that peripheral anticholinergic effects, such as tachycardia, dry mucous membranes, and hyperpyrexia are often not present, and incremental doses of physostigmine may be required to reverse scopolamine's long duration of action. This further complicates identification of the anticholinergic toxidrome and diagnosis.
东莨菪碱是一种强效抗胆碱能化合物，常用于预防术后恶心和呕吐。由于其显著的中枢抗毒蕈碱作用，东莨菪碱可导致非典型抗胆碱能综合征。
一名47岁女性在因右膝半月板切除术出院20小时后就诊于急诊科，术后12小时出现精神状态改变（AMS）和肢体张力障碍性运动。她的生命体征正常，体格检查发现瞳孔散大、视幻觉、反射亢进和张力障碍性运动。实验室检查、腰椎穿刺和计算机断层扫描均未发现异常。持续的AMS促使重新评估，超声检查发现有500毫升潴留尿导致尿潴留，且在她耳后发现一片隐藏的东莨菪碱贴片。移除贴片并给予毒扁豆碱后，她的精神状态很快改善，24小时后完全恢复，出院诊断为东莨菪碱诱导的抗胆碱能毒性。
急诊医生为何应了解此事？：尽管治疗剂量的东莨菪碱透皮贴剂很少引起并发症，但在多药联用情况下，不完全的中毒综合征可能隐匿常见。医护人员应彻底检查中毒患者的皮肤，寻找可能导致急诊科诊断和治疗延迟的其他粘附药物。我们的病例以及罕见的治疗性东莨菪碱诱导的抗胆碱能毒性病例报告表明，外周抗胆碱能作用，如心动过速、粘膜干燥和高热通常不存在，可能需要递增剂量的毒扁豆碱来逆转东莨菪碱的长效作用。这进一步使抗胆碱能中毒综合征的识别和诊断复杂化。
