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wikitox:cholinergictoxicity [2025/02/16 16:35] – created kharriswikitox:cholinergictoxicity [2025/02/17 00:33] (current) – kharris
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-Cholinergic Toxicity +====== Cholinergic Toxicity ======
- +
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 ===== Introduction ===== ===== Introduction =====
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 ===== Mechanism of Toxic Effects ===== ===== Mechanism of Toxic Effects =====
  
- Cholinergic toxicity occurs when there is excess acetylcholine activity in the body. This can occur from decreased breakdown of acetylcholine due to the presence of acetylcholinesterase inhibitors or direct stimulation by acetylcholine receptor agonists.+Cholinergic toxicity occurs when there is excess acetylcholine activity in the body. This can occur from decreased breakdown of acetylcholine due to the presence of acetylcholinesterase inhibitors or direct stimulation by acetylcholine receptor agonists. 
 + 
 +----
  
 ===== Cholinergic agents ===== ===== Cholinergic agents =====
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>**Acetylcholinesterase Inhibitors (effect both muscarinic and nicotinic system) include:**</font> 
  
-  * +**Acetylcholinesterase Inhibitors (effect both muscarinic and nicotinic system) include:**
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Organophosphate and carbamate pesticides</font> +
-  * +
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Nerve agents</font> +
-  * +
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Donepezil</font> +
-  * +
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Physostigmine, rivastigmine, neostigmine, pyridostigmine</font> +
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>**Acetylcholine receptor agonists include:**</font>+
  
-  * +   * Organophosphate and carbamate pesticides 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Nicotine receptor agonists</font>      * +  * Nerve agents 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Nicotine – nicotine containing products, nicotine in plants</font> +  * Donepezil 
-      * +  * Physostigmine, rivastigmine, neostigmine, pyridostigmine 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Varenicline</font> + 
-      * +**Acetylcholine receptor agonists include:** 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Neonicotinoid insecticides</font> +  * Nicotine receptor agonists 
-  * +      * Nicotine – nicotine containing products, nicotine in plants 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Muscarine receptor agonists</font>      * +      * Varenicline 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Mushroom species including  CKGE_TMP_i Amanita muscaria CKGE_TMP_i ,  CKGE_TMP_i Clitocybe CKGE_TMP_i  and  CKGE_TMP_i Inocybe sp CKGE_TMP_i .</font>+      * Neonicotinoid insecticides 
 +  * Muscarine receptor agonists 
 +      * Mushroom species including //Amanita muscaria//, //Clitocybe//  and //Inocybe sp//.
  
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 ===== Clinical Presentation ===== ===== Clinical Presentation =====
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>**CNS effects: **Coma, seizures, agitation/delirium</font> + 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>**Autonomic effects:** salivation, lacrimation, sweating, flushing, miosis</font> +**CNS effects:**  Coma, seizures, agitation/delirium \\  \\ **Autonomic effects:**  salivation, lacrimation, sweating, flushing, miosis \\  \\ **Neuromuscular effects:**  Fasciculations, weakness/paralysis \\  \\ **Cardiovascular effects:**  Bradycardia or tachycardia (common early), hyper/hypotension \\  \\ **Respiratory effects:**  Bronchoconstriction, bronchorrhea \\  \\ **Gastrointestinal effects:**  vomiting, diarrhoea
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>**Neuromuscular effects: **Fasciculations, weakness/paralysis</font> +
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>**Cardiovascular effects: **Bradycardia or tachycardia (common early), hyper/hypotension</font> +
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>**Respiratory effects: **Bronchoconstriction, bronchorrhea</font> +
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>**Gastrointestinal effects:** vomiting, diarrhoea</font>+
  
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 ===== Management ===== ===== Management =====
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>The main priorities in management are treatment of muscarinic effects and airway management. For advice regarding specific agents, see the relevant monograph.</font> + 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>**Antidote- Atropine:  **</font> +The main priorities in management are treatment of muscarinic effects and airway management. For advice regarding specific agents, see the relevant monograph. 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Treat muscarinic effects, particularly bradycardia and pulmonary secretions, early, with atropinisation. Atropine dosage can vary widely based on the causative agent and degree of toxicity. Toxicity secondary to organophosphates or carbamates may require cumulative doses of up to 100mg.</font> + 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>**Give: atropine 0.6mg (child 0.02 mg/kg up to 0.6mg) intravenously, repeat every 3-5 minutes, doubling the dose on each occasion until end-points achieved. **</font> +**Antidote- Atropine: ** \\  \\ 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>**  End-points: clear chest without wheeze, HR >80bpm, systolic BP >80.**</font> +Treat muscarinic effects, particularly bradycardia and pulmonary secretions, early, with atropinisation. Atropine dosage can vary widely based on the causative agent and degree of toxicity. Toxicity secondary to organophosphates or carbamates may require cumulative doses of up to 100mg. 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>It is common to require an ongoing infusion of 10-20% of the total dose of atropine required to achieve atropinisation of the patient per hour.</font> + 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>During titration observe for signs of over atropinisation (confusion, pyrexia, loss of bowel sounds).</font> +**Give: atropine 0.6mg (child 0.02 mg/kg up to 0.6mg) intravenously, repeat every 3-5 minutes, doubling the dose on each occasion until end-points achieved** 
- <font 11pt/Aptos,sans-serif;;inherit;;inherit>Intravenous benzodiazepines should be used to manage agitation and seizures.</font> + 
- <font 11.0pt/inherit;;inherit;;inherit>The exact role of pralidoxime is controversial and is discussed in more detail in the organophosphate monograph.</font>+**End-points: clear chest without wheeze, HR >80bpm, systolic BP >80.** 
 + 
 + \\ 
 +It is common to require an ongoing infusion of 10-20% of the total dose of atropine required to achieve atropinisation of the patient per hour. \\  \\ 
 +During titration observe for signs of over atropinisation (confusion, pyrexia, loss of bowel sounds). \\  \\ 
 +Intravenous benzodiazepines should be used to manage agitation and seizures. \\  \\ 
 +The exact role of pralidoxime is controversial and is discussed in more detail in the organophosphate monograph.
  
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