Volume 87 Number 6, part 1
Letters to the Editor
1011
necessity of specific countertherapy. If life-threatening anticholinergic manifestations of a cardiovascular nature alone predominate, then a quaternary amine such as neostigmine or pyridostigmine would be indicated, since these do not cross the bloodbrain barrier. If the life-threatening manifestations include the central nervous system, then a tertiary amine such as physostigmine has a place in the therapy, since it will cross the blood-brain barrier. Howard C. Mofenson, M.D. Joseph Greenshei; M.D. Poison Control Center Nassau County Medical Center East Meadow, N. Y. REFERENCES
1. Fig. 1.
Clearly, the safety of such apparatus must always depend on the constant vigilance of skilled nursing staff. Marion Williams, S.R.N., S.E.M., R.S.E.N. John Morgan, M.B., B.Ch., D.C.H., D.Obst. S. A. S. Thompson, M.R.C.P.(Edin), M.B.Ch.B., D.C.H., D.Obst. Maelor General Hospital Wrexham LL13 7TD England REFERENCE
1.
Krauss DR. and Marshall RE: Severe neck ulceration from CPAP head box, J PEDIATR 86:286, 1975.
Physostigmine as an antidote: Use with caution To the Editor: We would like to make several comments on the recent recommendations for the use of physostigmine salicylate as an antidote in accidental intoxications? -~ It is important that physostigmine not be recommended for routine use either in diazepam or even in the more serious tricyclic antidepressant intoxications. Our own experience and a review of the literature fail to reveal a case in which diazepam has caused a fatality, when it was the only drug ingested. Newton ~ has reported convulsions in two patients and severe cholinergic manifestations in two other patients in whom physostigmine was used intravenously. The severity and the type of manifestations caused by the poisonings should be the guide, in each individual case, for the
2. 3.
4.
Di Liberti J, O'Brien ML, and Turner T: The use of physostigmine as an antidote in accidental diazepam intoxication, J PEDIATR 86:106, 1975. Rumack BH: Anticholinergic poisoning: Treatment with physostigmine, Pediatrics 52:449, 1973. Hussey HH: Physostigmine: Value in treatment of central toxic effects of anticholinergic drugs. JAMA 231:1066, 1975. Newton RW: Physostigmine salicylate in the treatment o f tricyclic antidepressant overdose, JAMA 231:941, 1975.
To the Editor: We agree with Drs. Mofenson and Greensher that physostigmine should not be used routinely as an antidote for diazepam intoxication. Further experience is needed before the safety of and need for this therapy is established. The intent of our paper was to report an interesting observation and was n o t a recommendation for routine use. This was pointed out in the text.' The safety and usefulness ofphysostigmine for tricyclic antidepressant intoxication likewise remains to be demonstrated. The nature and severity o f side effects in Newton's ~ small group of patients are puzzling, since Bernards:' has seen no seizures or other significant complications after nearly 5,000 administered doses of physostigmine. Seizures and arrhythmias occur from tricyclic antidepressant intoxication alone. We believe that physostigmine is a relatively safe drug to use for reversal of toxic effects o f diazepam, phenothiazines, anticholinergic drugs, and possibly tricyclic antidepressants. Whether or not such therapy improves morbidity and mortality for these intoxications remains to be demonstrated. Intramuscular injection is probably associated with fewer side effects than intravenous use. Atropine should be available for immediate administration in the event that significant bradycardia or excess salivation occur. John 11. Di Liberti, M.D. Mary Lynn O'Brien, M.D. Pediatric Associates 999 North Curtis Rd Boise, Idaho 83704
Letters to the Editor
1011
necessity of specific countertherapy. If life-threatening anticholinergic manifestations of a cardiovascular nature alone predominate, then a quaternary amine such as neostigmine or pyridostigmine would be indicated, since these do not cross the bloodbrain barrier. If the life-threatening manifestations include the central nervous system, then a tertiary amine such as physostigmine has a place in the therapy, since it will cross the blood-brain barrier. Howard C. Mofenson, M.D. Joseph Greenshei; M.D. Poison Control Center Nassau County Medical Center East Meadow, N. Y. REFERENCES
1. Fig. 1.
Clearly, the safety of such apparatus must always depend on the constant vigilance of skilled nursing staff. Marion Williams, S.R.N., S.E.M., R.S.E.N. John Morgan, M.B., B.Ch., D.C.H., D.Obst. S. A. S. Thompson, M.R.C.P.(Edin), M.B.Ch.B., D.C.H., D.Obst. Maelor General Hospital Wrexham LL13 7TD England REFERENCE
1.
Krauss DR. and Marshall RE: Severe neck ulceration from CPAP head box, J PEDIATR 86:286, 1975.
Physostigmine as an antidote: Use with caution To the Editor: We would like to make several comments on the recent recommendations for the use of physostigmine salicylate as an antidote in accidental intoxications? -~ It is important that physostigmine not be recommended for routine use either in diazepam or even in the more serious tricyclic antidepressant intoxications. Our own experience and a review of the literature fail to reveal a case in which diazepam has caused a fatality, when it was the only drug ingested. Newton ~ has reported convulsions in two patients and severe cholinergic manifestations in two other patients in whom physostigmine was used intravenously. The severity and the type of manifestations caused by the poisonings should be the guide, in each individual case, for the
2. 3.
4.
Di Liberti J, O'Brien ML, and Turner T: The use of physostigmine as an antidote in accidental diazepam intoxication, J PEDIATR 86:106, 1975. Rumack BH: Anticholinergic poisoning: Treatment with physostigmine, Pediatrics 52:449, 1973. Hussey HH: Physostigmine: Value in treatment of central toxic effects of anticholinergic drugs. JAMA 231:1066, 1975. Newton RW: Physostigmine salicylate in the treatment o f tricyclic antidepressant overdose, JAMA 231:941, 1975.
To the Editor: We agree with Drs. Mofenson and Greensher that physostigmine should not be used routinely as an antidote for diazepam intoxication. Further experience is needed before the safety of and need for this therapy is established. The intent of our paper was to report an interesting observation and was n o t a recommendation for routine use. This was pointed out in the text.' The safety and usefulness ofphysostigmine for tricyclic antidepressant intoxication likewise remains to be demonstrated. The nature and severity o f side effects in Newton's ~ small group of patients are puzzling, since Bernards:' has seen no seizures or other significant complications after nearly 5,000 administered doses of physostigmine. Seizures and arrhythmias occur from tricyclic antidepressant intoxication alone. We believe that physostigmine is a relatively safe drug to use for reversal of toxic effects o f diazepam, phenothiazines, anticholinergic drugs, and possibly tricyclic antidepressants. Whether or not such therapy improves morbidity and mortality for these intoxications remains to be demonstrated. Intramuscular injection is probably associated with fewer side effects than intravenous use. Atropine should be available for immediate administration in the event that significant bradycardia or excess salivation occur. John 11. Di Liberti, M.D. Mary Lynn O'Brien, M.D. Pediatric Associates 999 North Curtis Rd Boise, Idaho 83704
