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TABLE 102.21 DRUGS AND CHEMICALS THAT MAY PRODUCE THE CENTRAL ANTICHOLINERGIC SYNDROME Antidepressants: Amitriptyline (Elavil), imipramine (Tofranil), doxepin (Sinequan, Adopin) Antihistamines: Chlorpheniramine (Ornade, Teldrin), diphenhydramine (Benadryl), orphenadrine (Norflex) Ophthalmologic preparations: Cyclopentolate (Cyclogyl), tropicamide (Mydriacyl) Antispasmodic agents: Propantheline (Probanthine), clidinium bromide (Librax) Antiparkinson agents: Trihexyphenidyl (Artane), benztropine (Cogentin), procyclidine (Kemadrin) Proprietary drugs: Sleep-Eze (scopolamine, methapyrilene), Sominex (scopolamine, methapyrilene), Asthma-Dor (belladonna alkaloids), ExcedrinPM (methapyrilene) Belladonna alkaloids: Atropine, homatropine, hyoscine, hyoscyamus, scopolamine Toxic plants: Mushroom (Amanita muscaria ), bitter-sweet (Solanum dulcamara ), Jimsonweed (Datura stramonium ), potato leaves and sprouts (Solanum tuberosum ), deadly nightshade (Atropa belladonna ) Clinical Considerations Clinical manifestations include tachycardia, mydriasis, facial flushing, hyperpyrexia, cardiac arrhythmias, urinary retention, dry mucous membranes, decreased sweating, and decreased or absent bowel sounds CNS effects include delirium, anxiety, hyperactivity, visual hallucinations, illusions, and disorientation These signs and symptoms lead to the common mnemonic, “Mad as a hatter, red as a beet, dry as a bone, blind as a bat, and hot as a hare.” In excess, anticholinergics may lead to severe toxicity that includes cardiac arrhythmias, seizures, and death The management of a patient with a known central anticholinergic syndrome is a challenge, particularly because one must also be prepared for the other distinct toxicities of the ingested drug or plant Most plants and many drugs in this category are not detected on toxicology screens, so the diagnosis must rely on