12-phase flow (12)

1. 1FRAME
   Recognize the antimuscarinic toxidrome and immediately stratify pure-antimuscarinic vs Na-channel co-toxic (TCA/diphenhydramine) — that split governs physostigmine eligibility [ACMT physostigmine guidance 2018]
   inputs: ingested_agent_and_dose
   advance: Toxidrome recognized; Na-channel co-tox risk flagged
2. 2ENTRY
   Trigger on agitated delirium + dry flushed skin, reported antimuscarinic ingestion, jimsonweed/Datura exposure, or the tachycardia + mydriasis + anhidrotic hyperthermia cluster [Burns 2000]
   inputs: age
   advance: Entry trigger captured
3. 3CONTEXT
   Capture agent, dose, formulation (sustained-release), time since ingestion, coingestants, polypharmacy anticholinergic burden, bladder/bowel status [2024 crit-care tox review]
   inputs: weight_kg, time_since_ingestion_and_formulation, coingestants, bladder_and_bowel_function
   advance: Agent + co-ingestion + formulation context complete
4. 4RED_FLAGS
   Mnemonic-anchored screen: blind as a bat (mydriasis/cycloplegia), mad as a hatter (delirium/agitation/hallucinations), red as a beet (flushed), hot as a hare (anhidrotic hyperthermia — mortality driver), dry as a bone (anhidrosis/dry mucosa), the bowel & bladder lose their tone (ileus, urinary retention), and the heart runs alone (sinus tachycardia); plus seizure, wide QRS Na-channel co-tox, severe agitation/rhabdo [Burns 2000]
   inputs: core_temperature, hr, sbp, mental_status_and_agitation_level, pupil_size_and_skin_exam
   actions: workup.severe_agitation, workup.first_seizure
   advance: Hyperthermia, Na-channel co-tox, and seizure screened; emergent cooling/sedation begun if positive
5. 5INITIAL_WORKUP
   MANDATORY 12-lead ECG (QRS width, terminal R in aVR, QT), antimuscarinic delirium screen, CMP, glucose, CK, lactate, ABG/VBG, APAP + salicylate co-screen, ethanol, urine tox, core temp, bladder scan [ACMT physostigmine guidance 2018; 2024 crit-care tox review]
   inputs: ecg_qrs_qt, creatine_kinase, acetaminophen_and_salicylate_level
   actions: workup.delirium, panel.tox_screen, panel.cardiac, panel.metabolic
   advance: ECG read for Na-channel/QT; metabolic + co-ingestion screen sent
6. 6BRANCHING_WORKUP
   Wide QRS or TCA → sodium-bicarbonate / Na-channel pathway (physostigmine OFF); pure antimuscarinic delirium + normal QRS → physostigmine-eligible pathway; hyperthermia → hyperthermic-toxidrome cooling pathway; isolated psychosis-like picture → reconcile against true psychosis [ACMT physostigmine guidance 2018]
   inputs: ecg_qrs_qt
   actions: workup.wide_complex_tach, workup.hyperthermic_toxidromes, workup.acute_psychosis
   advance: Branch selected (Na-channel vs pure-antimuscarinic vs hyperthermic)
7. 7DIFFERENTIAL
   Distinguish from sympathomimetic toxidrome (DIAPHORETIC/wet skin — sweat is the pivot), serotonin syndrome / NMS (clonus/rigidity), sepsis/meningoencephalitis, hyperthyroid storm, alcohol/sedative withdrawal, primary psychiatric delirium, heat stroke; peripheral antimuscarinic signs (dry skin, mydriasis, ileus, retention, tachycardia) distinguish from other delirium causes [Burns 2000]
   inputs: pupil_size_and_skin_exam
   advance: Anticholinergic confirmed as principal contributor; wet-vs-dry skin pivot applied
8. 8RISK_STRATIFICATION
   Severity bucket by hyperthermia (life-threatening driver), QRS widening (Na-channel co-tox), seizure, severe agitation/rhabdo, refractory delirium; qSOFA/NEWS2 for end-organ + disposition [2024 crit-care tox review]
   inputs: core_temperature, ecg_qrs_qt, mental_status_and_agitation_level
   actions: calc.qsofa, calc.news2
   advance: Severity classified; ICU disposition decided
9. 9TREATMENT
   Supportive first: benzodiazepine for agitation/seizure (FIRST-LINE), active cooling for hyperthermia (mortality driver), IV crystalloid, urinary catheter for retention; PHYSOSTIGMINE 1–2 mg slow IV over ≥5 min with continuous ECG + atropine at bedside ONLY for pure antimuscarinic delirium with both central + peripheral signs and normal QRS; SODIUM BICARBONATE if QRS wide (this overrides physostigmine); AVOID antipsychotics (worsen antimuscarinic + hyperthermia + QT) and physical-restraint-only without sedation (rhabdo/hyperthermia) [ACMT physostigmine guidance 2018; Burns 2000]
   inputs: mental_status_and_agitation_level, core_temperature, ecg_qrs_qt, weight_kg
   advance: Sedation + cooling active; physostigmine eligibility adjudicated; bicarbonate given if QRS wide
10. 10DISPOSITION
    ICU for hyperthermia, wide QRS / Na-channel co-tox, seizure, severe agitation requiring continuous sedation, or physostigmine administration; medical toxicology / poison centre consult; psychiatry if intentional; prolonged observation for Datura/jimsonweed (delayed, protracted course) [2025 crit-care tox review]
    advance: Disposition assigned; tox consult placed
11. 11MONITORING
    Continuous telemetry + ECG (re-check QRS/QT), q15–30 min core temp during cooling, mental status / agitation (RASS) hourly, CK + renal for rhabdo, recurrent toxicity after physostigmine wears off (short half-life — may need redose), bladder/UOP, post-bicarbonate QRS narrowing [Burns 2000]
    inputs: core_temperature, ecg_qrs_qt, creatine_kinase
    actions: panel.cardiac, panel.renal
    advance: Delirium clearing, normothermic, QRS narrow/stable, no rhabdo progression
12. 12FOLLOWUP
    Psychiatry safety plan if intentional; medication reconciliation / deprescribe anticholinergic burden (geriatric); poison-prevention + plant-identification education; renal follow-up if rhabdo-AKI; counsel that Datura/jimsonweed delirium can persist days [2025 crit-care tox review]
    advance: Safety plan + med reconciliation + return precautions documented