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Reversal of Amitriptyline Intoxication by Physostigmine

Bruce D. Snyder, MD; Lawrence Blonde, MD; William R. McWhirter, MD
JAMA. 1974;230(10):1433-1434. doi:10.1001/jama.1974.03240100051029.
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THIS article illustrates the rapid reversal of coma due to amitriptyline hydrochloride overdose by the administration of physostigmine salicylate. Physostigmine is the only commonly used specific cholinesterase inhibitor that readily penetrates the blood brain barrier.1

Slovis et al2 reported that physostigmine rapidly restored alertness and reversed tachycardia in four patients with amitriptyline intoxication. Rumack3 reported the successful use of physostigmine to treat children who became intoxicated by various agents with anticholinergic properties as well as the tricyclic antidepressants.

Report of Cases 

Case 1.—  A 27-year-old woman was admitted in coma to Martin Army Hospital on April 2, 1974. History provided by a friend indicated that after an alleged altercation with her estranged husband, the patient ingested 20 amitriptyline hydrochloride tablets (50 mg) and about 20 diazepam tablets (5 mg). When discovered by a neighbor, approximately 10 to 12 hours later, she could not be aroused. When seen


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