Template:Cholinergic Toxicity Treatment: Difference between revisions

Revision as of 22:11, 21 June 2015

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).

Antidotes

Atropine
- Competitively blocks muscarinic sites (does nothing for nicotinic-related muscle paralysis)
- May require massive dosage (hundreds of milligrams)
- Dosing^[1]
  - Adult: Initial bolus of 2-6mg IV; titrate by doubling dose q5-30m until tracheobronchial secretions controlled
    - Once secretions controlled → start IV gtt 0.02-0.08 mg/kg/hr
  - Child: 0.05-0.1mg/kg (at least 0.1mg) IV; repeat bolus q2-30m until tracheobronchial secretions controlled
    - Once secretions controlled → start IV gtt 0.025 mg/kg/hr
Pralidoxime
- For Organophosphate poisoning only.
- Has no use in Nicotinic poisoning
- Displaces an organophosphate from acetylcholinesterase (if given early)
- Dosing
  - Adult: 1-2gm IV over 5-10min; continuous infusion of 500mg/hr if no initial response
  - Child: 20-40mg/kg (up to 1gm) IV over 5-10min; 5-10mg/kg/hr if no initial response

↑ Agency for Toxic Substances and Disease Registry, Case Studies in Environmental Medicine, Cholinesterase Inhibitors: Including Pesticides and Chemical Warfare Nerve Agents. Centers for Disease Control (CDC). PDF Accessed 06/21/15

[CDC-1] Agency for Toxic Substances and Disease Registry, Case Studies in Environmental Medicine, Cholinesterase Inhibitors: Including Pesticides and Chemical Warfare Nerve Agents. Centers for Disease Control (CDC). PDF Accessed 06/21/15

[1]

@@ Line 1: / Line 1: @@
-===Protection===
-*Wear protective clothing to prevent secondary poisoning
-*Use neoprene or nitrile gloves (not latex)
 ===Decontamination===
-*Dispose of all clothes
+*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
-===Airway===
-*Suction as needed
+===Supportive Care===
-*Intubation often needed due to significant  respiratory secretions / bronchospasm
+*IVF, O2, Monitor
-*Use nondepolarizing agent ([[Rocuronium]] or [[Vecuronium]])
+*Aggressive airway management is of utmost importance.
-===Breathing===
+**Intubation often needed due to significant  respiratory secretions / bronchospasm.
-*Use O2 100% NRB
+**Use nondepolarizing agent ([[Rocuronium]] or [[Vecuronium]]).
 ===Antidotes===
 *'''Atropine'''
+**Competitively blocks muscarinic sites (does nothing for nicotinic-related muscle paralysis)
 **May require massive dosage (hundreds of milligrams)
-**Does not reverse muscle weakness due to nicotinic binding
+**Dosing<ref name="CDC">Agency for Toxic Substances and Disease Registry, Case Studies in Environmental Medicine, Cholinesterase Inhibitors: Including Pesticides and Chemical Warfare Nerve Agents. Centers for Disease Control (CDC). [http://www.atsdr.cdc.gov/csem/cholinesterase/docs/cholinesterase.pdf PDF] Accessed 06/21/15</ref>
-**Dosing
+***Adult: Initial bolus of 2-6mg IV; titrate by doubling dose q5-30m until tracheobronchial secretions controlled
-***Adult: 1mg or more IV; repeat q5min until tracheobronchial secretions attenuate
+****Once secretions controlled → start IV gtt 0.02-0.08 mg/kg/hr
-***Child: 0.01-0.04mg/kg (but never <0.1mg) IV
+***Child: 0.05-0.1mg/kg (at least 0.1mg) IV; repeat bolus q2-30m until tracheobronchial secretions controlled
+****Once secretions controlled → start IV gtt 0.025 mg/kg/hr
 *'''Pralidoxime'''
 **For Organophosphate poisoning only.