Cholinergic toxidrome

Background

Etiology

• Organophosphate poisoning from pesticides, insecticides, herbicides, and nerve agents
• Acetylcholinesterase inhibitor use including pyridostigmine and neostigmine

Clinical Manifestations

• Secretions everywhere
• Bronchorrhea, vomiting, diarrhea, diaphoresis, emesis, lacrimation, salivation, urination
• Miosis, blurred vision
• Confusion, weakness, seizures
• Muscle fascicultation
• Bradycardia, hypothermia, and tachypnea

Management

• Decontamination if ongoing skin exposure
• ABCs and intensive supportive care including early intubation
  • Avoid succinylcholine
  • Volume resuscitation without pressors is usually adequate
• Treat with anticholinergics
  • Atropine 2 to 5 mg IV, doubled every 3 to 5 minutes until clinically improved
    • Titrate to bronchorrhea, not tachycardia or mydriasis
    • May need hundreds of milligrams of atropine over several days
  • Can add pralidoxime to treat neuromuscular dysfunction
• Seizures: treated with benzos