Central anticholinergic syndrome from hyoscine hydrobromide in an unresponsive patient

Terminal agitation is common and causes severe distress for patients and loved ones. Careful assessment is of paramount importance in identifying a cause. PA patient with gastric adenocarcinoma who was admitted with adverse effects post-chemotherapy deteriorated acutely with a presumed intracerebral event. Secretions were an issue and hyoscine hydrobromide was commenced. Within twenty-four hours, the patient became acutely agitated and did not respond to standard treatment.After careful clinical examination out-ruling other causes, toxic psychosis secondary to hyoscine hydrobromide was felt to be most likely. Rotating anti-secretories and commencing a phenobarbitone infusion to treat severe agitation resulted in prolonged comfort before death.Inhibiting cholinergic transmission at central muscarinic receptors can cause psychosis, delirium, etc. Hyoscine hydrobromide crosses the blood brain barrier. This case demonstrates that even in unresponsive patients, it may cause agitation. If standard therapies are failing to control agitation, all possibilities must be considered. Central side effects of hyoscine hydrobromide may be a rare but under-recognised cause of agitation. This case demonstrates how through careful clinical assessment of possible differentials, and prompt and effective management of the most likely causes of distress, lasting comfort can be achieved. Patient with gastric adenocarcinoma who was admitted with adverse effects post-chemotherapy deteriorated acutely with a presumed intracerebral event. Secretions were an issue and hyoscine hydrobromide was commenced. Within twenty-four hours, the patient became acutely agitated and did not respond to standard treatment.