Template:Cholinergic Toxicity Treatment: Difference between revisions
(Add MedicationDose templates for atropine and pralidoxime in cholinergic toxicity)
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*'''First-line antidote''' — muscarinic antagonist; treats bronchorrhea, bronchospasm, bradycardia, and secretions<ref name="medscape"/>
*'''First-line antidote''' — muscarinic antagonist; treats bronchorrhea, bronchospasm, bradycardia, and secretions<ref name="medscape"/>
*'''Does NOT reverse nicotinic symptoms''' (weakness, fasciculations, paralysis)
*'''Does NOT reverse nicotinic symptoms''' (weakness, fasciculations, paralysis)
*Starting dose: '''1-2 mg IV''' (pediatric: 0.02-0.05 mg/kg, minimum 0.1 mg)
*Starting dose: {{MedicationDose|drug=Atropine|dose=1-2 mg IV (double q5min until atropinization)|route=IV|context=Cholinergic toxicity antidote (muscarinic)|indication={{PAGENAME}}|population=Adult|notes=May need 100+ mg in first 24h; endpoint is drying of secretions}}
*Pediatric: {{MedicationDose|drug=Atropine|dose=0.02-0.05 mg/kg IV (min 0.1 mg), double q5min|route=IV|context=Cholinergic toxicity antidote (muscarinic)|indication={{PAGENAME}}|population=Pediatric}}
*'''Doubling protocol''': If inadequate response after 5 minutes, double the dose (1 → 2 → 4 → 8 → 16 mg...) until atropinization is achieved<ref name="medscape"/>
*'''Doubling protocol''': If inadequate response after 5 minutes, double the dose (1 → 2 → 4 → 8 → 16 mg...) until atropinization is achieved<ref name="medscape"/>
*Massive doses may be required — total doses of 100+ mg in the first 24 hours have been reported<ref name="bmj"/>
*Massive doses may be required — total doses of 100+ mg in the first 24 hours have been reported<ref name="bmj"/>
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*'''Must be given before aging occurs''' (see [[#Aging and Oxime Window|aging table above]])
*'''Must be given before aging occurs''' (see [[#Aging and Oxime Window|aging table above]])
*Adult dose: '''1-2 g IV over 15-30 minutes''', may repeat in 1 hour; or '''30 mg/kg bolus then 8-10 mg/kg/hr continuous infusion'''<ref name="medscape"/>
*Adult dose: '''1-2 g IV over 15-30 minutes''', may repeat in 1 hour; or '''30 mg/kg bolus then 8-10 mg/kg/hr continuous infusion'''<ref name="medscape"/>
*Pediatric dose: 20-50 mg/kg IV, then 5-10 mg/kg/hr infusion
*Pediatric: {{MedicationDose|drug=Pralidoxime|dose=20-50 mg/kg IV, then 5-10 mg/kg/hr infusion|route=IV|context=Cholinergic toxicity (oxime reactivator)|indication={{PAGENAME}}|population=Pediatric}}
*Continue until clinical improvement or patient is off ventilator
*Continue until clinical improvement or patient is off ventilator
*'''Controversies''':
*'''Controversies''':

Revision as of 22:38, 20 March 2026

Decontamination

  • Providers should wear appropriate PPE during decontamination.
    • Neoprene or nitrile gloves and gown (latex and vinyl are ineffective)
  • Dispose of all clothes in biohazard container
  • Wash patient with soap and water

Supportive Care

  • IVF, O2, Monitor
  • Aggressive airway management is of utmost importance.
    • Intubation often needed due to significant respiratory secretions / bronchospasm.
    • Use nondepolarizing agent (Rocuronium or Vecuronium)
    • Succinylcholine is absolutely contraindicated
  • Benzodiazepines for seizures

Antidotes

  • Dosing with atropine and pralidoxime are time dependent and provides ability to reverse symptoms while awaiting agent metabolism
  • For exposure to nerve agents, manufactured IM autoinjectors are available for rapid administration:
    • Mark 1
      • Contains 2 separate cartridges: atropine 2 mg + 2-PAM 600 mg
      • Being phased out with newer kits
    • DuoDote
      • Single autoinjector containing both medications
      • Same doses as Mark 1: atropine 2 mg + 2-PAM 600 mg

Antidotes

Atropine

  • First-line antidote — muscarinic antagonist; treats bronchorrhea, bronchospasm, bradycardia, and secretions[1]
  • Does NOT reverse nicotinic symptoms (weakness, fasciculations, paralysis)
  • Starting dose: Atropine 1-2 mg IV (double q5min until atropinization) IV — May need 100+ mg in first 24h; endpoint is drying of secretions
  • Pediatric: Atropine 0.02-0.05 mg/kg IV (min 0.1 mg), double q5min IV
  • Doubling protocol: If inadequate response after 5 minutes, double the dose (1 → 2 → 4 → 8 → 16 mg...) until atropinization is achieved[1]
  • Massive doses may be required — total doses of 100+ mg in the first 24 hours have been reported[2]
  • Endpoints of adequate atropinization (goal of therapy):
    • Drying of bronchial secretions (most important endpoint)
    • Heart rate >80 bpm
    • Systolic BP >80 mmHg
  • Do NOT target: Fully dilated pupils, absent bowel sounds, or HR >150 — these indicate atropine toxicity[3]
  • After initial atropinization: Consider atropine infusion (10-20% of loading dose per hour) to maintain effect
  • Optimize oxygenation before giving atropine to reduce risk of dysrhythmias (though in resource-limited settings, do not withhold atropine waiting for oxygen)[2]


Pralidoxime

  • AKA 2-PAM
  • Oxime that reactivates phosphorylated AChE → primarily reverses nicotinic symptoms (weakness, fasciculations, respiratory muscle paralysis)[4]
  • Must give atropine BEFORE pralidoxime to prevent worsening of muscarinic symptoms
  • Must be given before aging occurs (see aging table above)
  • Adult dose: 1-2 g IV over 15-30 minutes, may repeat in 1 hour; or 30 mg/kg bolus then 8-10 mg/kg/hr continuous infusion[1]
  • Pediatric: Pralidoxime 20-50 mg/kg IV, then 5-10 mg/kg/hr infusion IV
  • Continue until clinical improvement or patient is off ventilator
  • Controversies:
    • Evidence for benefit of pralidoxime is inconsistent; several meta-analyses have not shown clear mortality benefit when added to atropine[5]
    • However, per AHA 2023 guidelines and expert consensus, oximes should still be given for significant OP poisoning, particularly when fasciculations, weakness, or paralysis are present[1]
    • Efficacy depends on timing (before aging), dose, and the specific OP compound involved
  • Caution: Administer slowly — rapid IV push can cause hypertensive crisis, cardiac arrest
  1. ↑ 1.0 1.1 1.2 1.3 Cite error: Invalid <ref> tag; no text was provided for refs named medscape
  2. ↑ 2.0 2.1 Cite error: Invalid <ref> tag; no text was provided for refs named bmj
  3. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named wfsa
  4. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named pralidoxime_statpearls
  5. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named prognosis
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