Template:Cholinergic Toxicity Treatment: Difference between revisions

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**Use nondepolarizing agent ([[Rocuronium]] or [[Vecuronium]]).
**Use nondepolarizing agent ([[Rocuronium]] or [[Vecuronium]]).


===Antidotes===
==Antidotes==
*'''[[Atropine]]'''
===[[Atropine]]===
**Competitively blocks muscarinic sites (does nothing for nicotinic-related muscle paralysis)
*Competitively blocks muscarinic sites (does nothing for nicotinic-related muscle paralysis)
**May require massive dosage (hundreds of milligrams)
*May require massive dosage (hundreds of milligrams)
**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<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>  
***Adult: Initial bolus of 2-6mg IV; titrate by doubling dose q5-30m until tracheobronchial secretions controlled
*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
**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
**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
**Once secretions controlled → start IV gtt 0.025 mg/kg/hr
*'''[[Pralidoxime]]'''
===[[Pralidoxime]]===
**AKA 2-PAM
*AKA 2-PAM
**For Organophosphate poisoning only - reactivates AChE by removing phosphate group → oxime-OP complex then excreted by kidneys.
*For Organophosphate poisoning only - reactivates AChE by removing phosphate group → oxime-OP complex then excreted by kidneys.
***This must be done before "aging" occurs - conformational change that makes OP bond to AChE irreversible.
**This must be done before "aging" occurs - conformational change that makes OP bond to AChE irreversible.
**Dosing<ref name="CDC" />
*Dosing<ref name="CDC" />
***Adult: 1-2gm IV over 15-30min; repeat in 1 hour if needed '''or''' 50 mg/hr infusion.
**Adult: 1-2gm IV over 15-30min; repeat in 1 hour if needed '''or''' 50 mg/hr infusion.
***Child: 20-40mg/kg IV over 20min; repeat in 1 hour if needed '''or''' 10-20 mg/kg/hr infusion.
**Child: 20-40mg/kg IV over 20min; repeat in 1 hour if needed '''or''' 10-20 mg/kg/hr infusion.

Revision as of 20:59, 14 May 2017

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

  • AKA 2-PAM
  • For Organophosphate poisoning only - reactivates AChE by removing phosphate group → oxime-OP complex then excreted by kidneys.
    • This must be done before "aging" occurs - conformational change that makes OP bond to AChE irreversible.
  • Dosing[1]
    • Adult: 1-2gm IV over 15-30min; repeat in 1 hour if needed or 50 mg/hr infusion.
    • Child: 20-40mg/kg IV over 20min; repeat in 1 hour if needed or 10-20 mg/kg/hr infusion.
  1. ↑ 1.0 1.1 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
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