Ver el código de «Cholinergic crisis»

==Background==
*Neuromuscular junction over-stimulation due to an excess of acetylcholine (ACh), as of a result of the inhibition of the AChE enzyme (which normally breaks down acetylcholine)

===Pathophysiology===
*The neuromuscular junction, where the brain communicates with muscles (e.g. the diaphragm), works by acetylcholine activating nicotinic acetylcholine receptors and leading to muscle contraction. 
*Atropine blocks muscarinic acetylcholine receptors (a different subtype than the nicotinic receptors at the neuromuscular junction), so will not improve the muscle strength and ability to breathe. 
**So, such patients will frequently require mechanical ventilation until the crisis resolves. There is not specific antidote for the respiratory compromise.

{{Autonomic nervous system receptors}}

==Clinical Features==
===SLUDGE(M) syndrome===
'''S'''alivation, '''L'''acrimation, '''U'''rination, '''D'''iarrhea, '''G'''I pain, '''E'''mesis, '''M'''iosis

==Differential Diagnosis==
{{SLUDGE DDX}}

==Evaluation==
{{Myasthenic vs cholinergic crisis}}

==Management==
*Decontaminate immediately - takes priority, prevent exposure of health care workers, remove patient from exposure and remove all clothing
*[[Atropine]] (antimuscarinic)
**2-4mg IV q5min, titrate to resolution of bronchorrhea (may need > 100 mg total dose)
**Then initiate atropine infusion at 10% of total initial dose and titrate up by 0.2 mg/kg/hr to maintain resolution of bronchorrhea
*[[Benzodiazepines]] prn for seizures
**Lorazepam 2-4 mg IV
*Pralidoxime (2-PAM)
**Loading dose 20 mg/kg (max 2 g) IV bolus x 30 minutes then
**Infusion 8-10 mg/kg/hr (max 650 mg/hr) IV
*Consider [[intubation]] and [[mechanical ventilation]]
**Poisoning of acetylcholinesterase will prolong effects of succinylcholine.  Consider nondepolarizing agent such as [[rocuronium]] if paralytic needed

==Disposition==
*Admit, consider ICU

==See Also==
*[[Toxidromes]]
*[[Physostigmine]]

==External Links==


==References==
<references/>

[[Category:Toxicology]]