A probable case of collapse due to hyoscine patch

Background

Hyoscine is a belladonna alkaloid with anticholinergic properties. It competes with acetylcholine and other parasympathomimetic agents thus blocking their effects at parasympathetic sites at the nicotinic and muscarinic receptors. It causes decreased motility in the gastrointestinal and urogenital tract as well as having inhibitory actions on salivary glands, respiratory tract and the oral cavity.

Hyoscine is available as an over-the-counter medication for nausea, vomiting as well as motion sickness. It is commonly used to treat abdominal pain seen in gastroenteritis, colitis, inflammatory bowel disease, ureteric colic and primary dysmenorrhoea.

The side effects of hyoscine can be as follows1 2:

• Very common—dryness of mouth, visual disturbance (blurred vision, cycloplegia, myopia, mydriasis), hot skin, dizziness, dyspepsia, palpitations.

• Common—skin irritation.

• Rare—confusion, memory impairment, disorientation, restlessness, urinary retention.

Side effects can be remembered by the phrase ‘blind as a bat, dry as a bone, full as a flask (urinary retention), hot as a hare, red as a beet, and mad as a hatter’.3

Case presentation

An 80-year-old man presented with an unwitnessed fall with a subsequent long lie. His partner, who found him lying on the floor outside his room, noticed that he was not quite himself with profound confusion and slurred speech. He then had expressive dysphasia and continued to be floridly delirious up until and during his admission. Prior to this, he was independently mobile, carrying out all activities of daily living and even running marathons not too long ago.

His medical history revealed a previous stroke, ischaemic heart disease with atrial fibrillation, benign prostatic hyperplasia (BPH) and Bell’s palsy. His regular medications consisted of apixaban 5 mg two times a day, quinine sulfate 300 mg one time a day, simvastatin 40 mg one time a day, co-codamol (codeine 30 mg/paracetamol 500 mg) two tabs three times a day, and perindopril 8 mg one time a day. The patient was also using hyaluronic acid lubricating eye drop three times a day and xailin lubricating eye ointment one time a day in the left eye. His general practitioner (GP) prescribed him hyoscine butylbromide 10 mg two tablets four times a day, 15 days before his hospital admission for excessive salivation. Then, the tablets were changed to transdermal patch 1 mg/72 hours after 4 days so that it would be more convenient for the patient rather than to take the tablets.

On physical examination, the patient was confused and not oriented to time, place or person. He was agitated and had generalised tremors, particularly in his upper limbs. His tongue appeared very dry with a white coating. He had dry and hot skin. His blood pressure was 154/90 mm of Hg, pulse rate 109 beats/min, temperature 35.8°C, respiratory rate 18 breaths/min, and oxygen saturation was 98% at room air. Capillary blood glucose level was 8.9 mmol and his glasgow coma scale (GCS) score was 13/15 (E4 V3 M6). He had slurred speech which was very difficult to comprehend. Loss of forehead wrinkles and a minimal right facial droop was noted in keeping with Bell’s Palsy. Pupils were equal, round, regular in size and reactive to light bilaterally. Neurological examination revealed power of 4+/5 in all limbs with decreased sensation on the left side. Abdomen was generally distended with a palpable bladder. Digital rectal examination was normal.

Investigations

Routine blood tests showed a raised white cell count of 13.4, and a C reactive protein (CRP) of 103.7 mg/L. Renal function and liver function were normal. Interestingly, the creatine kinase (CK) was raised at 5028 IU/L. Chest X-ray showed subtle changes in both bases with a CT head showing nothing acute. MRI Head could not be performed due to an intraocular metallic clip designed to aid patients with severe Bell’s palsy blink. Flexible nasal endoscopy was done which revealed left sluggish vocal fold.

Differential diagnosis

The patient was evaluated by the stroke team at the emergency department with the possibility of acute stroke was ruled out by the findings of urgent CT head. He was treated for aspiration pneumonia with intravenous antibiotics. His high CK level was due to rhabdomyolysis which resulted from fall with long lie, and possibly aggravated by the use of statin. It was treated with aggressive intravenous rehydration. Slurred speech could be due to the left sluggish vocal cord which resulted from the previous stroke. Rest of his symptoms like tremors, agitation and confusion which were probably due to the hyoscine patch behind his left ear. The cause of urinary retention may be attributed to hyoscine which increased the risk with his background history of BPH.2

Treatment

The patient was treated for aspiration pneumonia with antibiotics. He was catheterised in the ward as he had acute urinary retention. The hyoscine patch was removed. The skin below the patch was intact. Oral care was done as his oral cavity and tongue looked parched. He was kept nil by mouth till he was assessed by the dietician to assess his swallowing. He was seen by the physiotherapists who assessed his mobility. He failed his catheter removal and was started on tamsulosin. Statin was stopped.

Outcome and follow-up

His symptoms improved markedly after removal of the patch. The tremors and agitation stopped. He became alert, oriented to time, place and person. His CK level returned back to normal after treating with intravenous fluid and stopping statin. His speech has improved but has not returned to baseline. His swallowing improved and was able to take oral food and fluids. The speech and language therapist reviewed him for vocal rehabilitation. The physiotherapists reviewed his mobility.

He was then transferred to rehabilitation ward where he was seen by the multidisciplinary teams including physiotherapists, occupational therapists and speech and language therapists. His mobility did not improve significantly despite the physiotherapy, and needed hoist for all transfers throughout his stay. Dieticians have reviewed him and changed his diet to pureed form. He also has some degree of cognitive impairment. He failed his catheter removal two more times.

He was transferred to nursing home as he needs 24-hour care after he became medically fit. The medical team discussed about resuscitation plans for future with his wife and she has agreed not to resuscitate him due to factors like his age, and, his medical history which could lead to poor outcome. Overall, he was in the hospital for 4 months. The reversible causes contributing to collapse, rhabdomyolysis, agitations, confusion, poor mobility and urinary retention were treated. The hyoscine patch which was probably responsible for his symptoms was removed and stopped. However, the patient did not recover completely, and still had some issues especially with his mobility. This can be contributed to his previous history of stroke.