Template:Cholinergic Toxicity Treatment

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

• 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
  • DuoDate
    • Single autoinjector containing both medications
    • Same doses as Mark 1: atropine 2 mg + 2-PAM 600 mg

Antidotes

Atropine

• Competitively blocks muscarinic sites (does nothing for nicotinic-related muscle paralysis)
• May require massive dosage (hundreds of milligrams)
• Dosing
• 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
  • 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.