Clinical Practice and Cases in Emergency Medicine

Introduction: Antimuscarinic toxicity, which can cause delirium and unsafe behavior, may result from an adverse effect of prescribed medications or from non-medical substance use. Physostigmine shortages have prompted use of transdermal rivastigmine for management of antimuscarinic toxicity; however, symptom control is equivocal at standard dosing.

Case Report: A patient with antimuscarinic toxicity was treated with physostigmine and transitioned to 26.6 milligrams/24 hours transdermal rivastigmine for sustained symptom control. He experienced no adverse effects and tolerated floor admission.

Discussion: There is mechanistic plausibility supporting safe, sustained control of antimuscarinic toxicity with high-dose transdermal rivastigmine. Central distribution is more rapid than serum distribution and higher doses correlate with a shorter time to peak concentration.