Anticholinergic syndrome is a type of intoxication with neurological symptoms. The most common causes are drug overdoses or opiate use. Treatment options include gastric lavage, diuresis, or therapy with activated charcoal.
What is anticholinergic syndrome?
The term “anticholinergic” means opposing the action of acetylcholine. Acetylcholine is a neurotransmitter. Many stimuli within the central and peripheral nervous systems are transmitted via this neurotransmitter. The contractions of the skeletal muscles, for example, are commissioned and realized via this substance. In addition, the neurotransmitter serves as a signaling substance within the sympathetic and parasympathetic brain regions. In anticholinergic syndrome, this signal transduction is disturbed. As a result of the phenomenon, the parasympathetic nervous system shuts down almost completely. As a rule, this phenomenon occurs as a result of the consumption of toxic substances. Thus, the anticholinergic syndrome is a kind of poisoning phenomenon. Neurological symptoms characterize the picture of the syndrome. Sometimes there is also talk of mind-altering effects in this context.
Causes
Most commonly, anticholinergic syndrome occurs in the context of drug overdose. However, to some extent, consumption of nightshade plants is also responsible for the phenomenon. Among the drugs, antidepressants and neuroleptics, as well as antihistamines and hyoscyamine have anticholinergic effects. Among the nightshade plants, belladonna, angel’s trumpet, and henbane or datura in particular have anticholinergic effects. The plants and drugs mentioned contain antagonists to the neurotransmitter acetylcholine and therefore show inhibitory effects on the parasympathetic nervous system. In nightshade plants, the highly toxic tropane alkaloid atropine is primarily responsible for the inhibitory effect. This substance competes with acetylcholine in the organism and displaces the acetylcholine receptors. Thus, atropine antagonizes the effects of natural acetylcholine and disrupts consciousness.
Symptoms, complaints, and signs
Patients with anticholinergic syndrome usually feel confused and disoriented. Seizures often occur in addition to anxiety and agitation. Auditory and visual hallucinations or generalized movement disorders are also among the symptoms. These symptoms of the syndrome form a separate form of the phenomenon, often referred to as the deliriant form. To be distinguished from this is the somnolent form. It manifests itself in drowsiness up to coma. In extreme cases, respiratory arrest occurs. Both forms of the phenomenon can be accompanied by accompanying symptoms, such as dry, reddened or heated skin. Fever often occurs with both. Sweat production may decrease and pupils dilate. Glaucoma attacks or blurred vision are also common. Other accompanying symptoms include dysphagia, cardiac arrhythmias, and dry mouth due to decreased saliva production. In addition, the gastrointestinal tract and bladder are often inhibited by intoxication.
Diagnosis and course
Physicians distinguish between a peripheral and a central anticholinergic syndrome. Peripheral and central in this context refer to the respective involvement of the nervous system. For example, the peripheral anticholinergic syndrome manifests predominantly as hypertonia of the skeletal muscles. The central form, on the other hand, can involve severe alterations in character and clouding of consciousness, as it attacks the central nervous system perceptual apparatus. The course of the poisoning symptom depends greatly on the form. The somnolent form of the syndrome is usually less prognostic than the deliriant form. Usually, patients of the anticholinergic syndrome do not present with all symptoms together. Often, their complaints are nonspecific. The syndrome is therefore difficult to diagnose unless the history suggests it. Both cerebral hemorrhage and inflammation in the brain can present with similar symptoms. However, the physostigimine test can confirm the suspicion of anticholinergic syndrome. The prognosis is generally good as long as the syndrome is detected early. Permanent damage is usually not expected.
Complications
Because of the complexity of the syndrome, reactions vary. A distinction is made between central as well as peripheral anticholinergic syndrome.The latter is manifested by urinary retention, intestinal blockage, acute circulatory problems, enlarged pupils, skin irritation, and dry mouth. Central anticholinergic syndrome affects only the brain and spinal cord. Symptoms include a decrease in cognition, aggressiveness, restlessness, and hallucinations. Patients who show symptoms after taking the medication should receive immediate medical attention. Complications range from dizziness to cerebral dysfunction, intracranial pressure, cerebral hemorrhage, viral encephalitis, and increased risk of stroke. Patients with hydrocephalus are also more likely to succumb to anticholinergic syndrome, as are patients with seizure disorders. If unconsciousness has already occurred, the affected person belongs to the intensive care unit for monitoring. Once the drug intolerance has been clarified, the affected person is enabled to excrete the causative substance by means of infusion or activated charcoal. Physostigmine is only administered in an emergency, as it involves further side effects. After treatment, affected individuals must avoid the causative compounds.
When should you see a doctor?
If permanent confusion or disorientation occurs after taking antidepressants, neuroleptics, and antihistamines, or consuming nightshade. a doctor must be consulted immediately. Other warning signs of anticholinergic syndrome include seizures, anxiety and agitation, and generalized movement disorders and visual and auditory hallucinations. Also characteristic are the typical accompanying symptoms: Dry mouth, dysphagia, sore throat, fever, and severely decreased sweat production. External features such as dilated pupils and red, dry skin should also lead directly to the doctor. The physician can then diagnose the condition and determine whether it is the deliriant or somnolent form. Further treatment (gastric lavage and administration of medication) should be given immediately. Therefore, it is recommended to consult the general practitioner or hospital immediately if anticholinergic syndrome is suspected. In case of severe seizures, breathing difficulties or unconsciousness, the emergency physician must be called. Until medical help arrives, other first aid measures may need to be taken.
Treatment and therapy
If hallucinations or extreme agitation occur, a patient with anticholinergic syndrome may need to be restrained to prevent self-harm. Fixation is also used to protect the staff providing treatment. Anticholinergic syndrome may also be associated with external aggression. Physostigmine may be administered as an antidote. This antidote is usually administered via a perfusor. This administration must be done with strict attention to side effects and contraindications. In severe cases of anticholinergic syndrome, the patient must be monitored and cared for in an intensive care setting. If necessary, the physician can accelerate the excretion of toxins by means of artificially forced diuresis. He can thus stimulate the kidneys to work by means of various procedures. If the benefit to the patient outweighs the risk of gastric lavage, then gastric emptying measures can also be initiated. Specifically, gastric lavage is often indicated for unconscious or unconscious patients. With the aid of activated charcoal, the patient’s gastrointestinal tract may also be prevented from continuing to absorb toxins into the blood.
Outlook and prognosis
The prognosis of anticholinergic syndrome is considered good. Once the cause is identified, treated, and corrected, recovery and complete freedom from symptoms occur. The sooner a diagnosis is made and treatment begins, the faster the recovery. Within a few hours after the start of therapy, significant improvements in the state of health can already be seen. In the coming days, the overdosed active substances from the medication are almost completely eliminated from the body. The aggressive tendencies subside and symptoms such as hallucinations as well as delusions no longer occur. After a few weeks of medical care, many patients are already fully and permanently cured physically. The recovery phase after the disease still takes some time in many cases, but a relapse is considered rather unlikely. The body merely needs some time to build up its strength.In a severe manifestation of anticholinergic syndrome, permanent damage to the brain may be present in exceptional cases. These can lead to permanent changes in personality or to the development of other mental illnesses. Nevertheless, the risk of permanent impairment is considered to be extremely low. More serious can be the secondary disorders. Psychological stress, anxiety and trauma are possible. The illnesses reduce the sense of well-being. Psychotherapy is often needed for a cure.
Prevention
Anticholinergic syndrome can be prevented by proper dosing of medications and avoidance of the toxins mentioned above. Specifically, refrain from consumption of all opiates, atropine, or atropine-containing substances. After an anticholinergic syndrome as a result of drug administration, the patient should never be exposed to the causative substances again, if possible.
Follow-up
In most cases, no special options or measures of aftercare are necessary or possible in this syndrome. However, the affected person is thereby dependent on a quick diagnosis and on the subsequent treatment, so that it does not come to further complaints or in the worst case to the death of the affected person. Therefore, a doctor should be consulted at the first signs or symptoms of this syndrome. If there is no immediate treatment, the symptoms usually worsen and eventually lead to the death of the affected person. The treatment itself should always be carried out by the attending physician, as he is usually familiar with the medications taken. The symptoms are often alleviated with the help of activated charcoal. In this case, the affected person is dependent on regular and correct intake in order to counteract the poisoning. A permanent control and monitoring of the affected person is also necessary in this syndrome. Whether it comes thereby to a healing or to a reduced life expectancy, cannot be predicted thereby universally. It is not uncommon for gastric lavage to be necessary in this case. The cause of the poisoning should be prevented in the further course of course.
This is what you can do yourself
People with anticholinergic syndrome should always have glucose, blood pressure monitor and blood glucose indicator handy in the household. If they have a seizure due to this syndrome, they must call for an ambulance immediately. The strong disturbances of consciousness can be delayed, if the affected person sits down at the open window and drinks as much pure water or laxative tea as possible. Tablets are to be avoided in any case. Often the circulation can still be kept in a stable state with fiber-rich food. Anticholinergic syndrome sufferers are well advised to give a spare key to a neighbor who can be reached frequently. Regular telephone calls and, if possible, visits several times a day should also reassure the sufferer that he or she will receive help quickly in the event of a serious attack. Since people suffering from this type of illness can only receive proper treatment in an intensive care unit, the packed bag should be placed in such a way that it is just as visible to third parties as a telephone list for emergencies. In therapeutic treatment, correct breathing techniques can be learned at an early stage. Likewise, relaxation exercises can be trained so that the body functions immediately switch to reserve in an emergency, so that further symptoms of poisoning do not worsen. Psychological therapists can also provide helpful support here in advance. In addition, a visit to a nutritionist is advised in order to use food to bring the metabolism into balance in the long term.
