UMEM Educational Pearls

Category: Toxicology

Title: Physostigmine for Anticholinergic Poisoning

Keywords: physostigmine, anticholinergic (PubMed Search)

Posted: 6/10/2010 by Bryan Hayes, PharmD (Updated: 9/27/2023)
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Physostigmine has been used extensively in the fields of anesthesiology and emergency medicine.  The only use of physostigmine with sound scientific support is for the management of patients with an anticholinergic syndrome, particularly those without cardiovascular compromise who have an agitated delirium.  In this population, physostigmine has an excellent risk-to-benefit profile.

  • Try benzodiazepines first.  They last longer and may diminish the need for physostigmine.
  • Obtain ECG.  If there are signs of sodium channel blockade (QRS prolongation), do not use physostigmine.
  • Administer 1-2 mg via slow IV push/infusion over at least 5 minutes.
  • Have atropine available at the bedside.
  • Effects last about 1 hour.